Page 370 - Ebook health insurance IC27

The Insurance Times

 At times histopathology reports usually not available in surgical cases.
 Documentations are usually in order.
 Similar handwriting / over writing
 In most fraudulent claims the treating doctor, agents, ailments are the same.
 Medicine bills in serial order.
 Member purchasing medicine far from the place of residence or provider.
 Patient residence and the hospital address are not geographically same.
 Fraud claimers are short term policy holders with lower sum insured.
 Claims registered immediately after the waiting period is over
 Higher per-patient cost.
 Excessive per-doctor patients.
 Higher per-patient test.
 Higher per-patient average visit numbers.
 Per-patient average medical tests.
 Fluctuating monthly claims of the providers
 Double billing

Managing fraud is one of the most challenging and costly realities, which insurers,
government, different regulatory authorities and society cannot afford to overlook.
There is a need for participation of the honest stakeholders to jointly address the
most burning issue in healthcare industry. All the insurers need to join hands and
form a committee for tackling fraudulent claims.

374 Guide for Health Insurance