Health care fraud is perpetuated in many different ways and every Insurance Company is affected, whatever geography that they operate in. Moral hazards as an exmple are common in both developing and advanced nations where billing happens for services not rendered.
Other common types of insurance fraud include:
• Performing unnecessary procedures for higher profit
• Misrepresenting uncovered treatments as covered
• Accepting kickbacks for patient referrals
• Waiving co-pays to up-bill a patient’s insurance
But all these can be controlled with some technical enabled methodologies like:
- Improve security with Biometrics
- Find fraud patterns with predictive modelling
- Detect Fraud with AI
- Using block chain to track data
- Implementing smart cards
Manorama’s Solutions address the detection and prevention of several frauds, some of these are listed below:
- One-time procedure reported many times
Where a rule based check is available to avail certain services number of times per beneficiary per policy - Gender/Age mismatch
Where gender based rules are set so that there will not be any fraud for raising a claim for a male patient for gynaecology department. Member on boarding will have validations as per the age limits set in policy configuration - Diagnosis and treatment contradict each other
Where there will be standard treatment guidelines which will help controlling fraud - Claims in a day beyond Hospital Bed capacity
Where system has a check on each providers bed capacity which will prevent raising claims for IPD patients beyond the defined bed size or it will be notified to the Insurer through an auto email
