Frauds and Abuses In Health Insurance Claims: An Insight

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Introduction to Health Insurance 

Health Insurance covers your medical expenses and ensures that you are not overburdened or compromised financially because of your health. 

Statistics reveal the trend of opting for health insurance is increasing over the years.According to research, average health insurance plans have reached up to $ 7,188 for an individual and $20,576 for families in 2019, 4% greater than last year, i.e., 2018.

Role of Health Insurance In The Society 

So, how does Health Insurance help people? What are the benefits?

Here are a few significant facts that highlight the role of Health Insurance in our society today: 

  • Promotion of Health: 
    • Through Health Insurance, treatment options are more accessible and affordable to everyone. People adhere to their follow-ups, routine examinations showing how Health Insurance promotes health too apart from the financial benefit.
  • Financial Security: 
    • Patients who live with comorbidities face several complications now and then. For example, cancer patients aren’t sure when their treatment would end. Health Insurance works as a protective barrier in such a scenario. Patients and their families can smoothly carry on with their respective treatments because insurance covers all the expenses. 
  • Easy Access to Health Care: 
    • Because of health care insurance, people are now more willing to go for their appointments with doctors. What once was considered annual visits have now changed into monthly visits.  People have easier access to their doctors and can easily avail of the benefits that come with their customized insurance plans.  

All of this, along with several other factors, helps people lead a healthy and peaceful life with accessible healthcare access whenever required.

The Other Side: Health Care Insurance-Related Scams and Frauds 

Yes, this side of the story was often overlooked until recently. It was indeed a surprising and shocking revelation for the healthcare insurance companies that the healthcare providers and public was misusing their policies and their benefits. 

What started as a humanitarian and peaceful act turned into a selfish act of greed. Furthermore, the people misusing these insurance policies were not the healthcare insurance companies themselves but were the healthcare providers and patients. 

And what is more shocking here is – some of the hospitals and medical practitioners are found to be involved continuously in this crime.

Health care insurance frauds have become a trending topic now. Insurance fraud is a severe criminal offence in the United States. 

Enlisted below is a brief overview that explores the different types of frauds and ‘misuse of authorities’ against the health care insurance companies: 

Frauds Committed By The Patients:

  • Faking Identity:
    • Some people – out of their ‘helpful’ nature, let their friends or family healthcare services on their behalf, using their healthcare insurance. This is a severe crime and is burdening the healthcare company by ‘enjoying the perks.’ 
  • Extra Usage: 
    • Some people might start relying too much on their insurance companies without letting them know about it. This includes buying non prescribed medicines, forging prescriptions, or tampering with bills.

Frauds Committed By The Healthcare Providers: 

  • Upcoding: 
    • Upcoding is a practice where a hospital charges a patient more for a service than what it costs. Further, to prove the ‘innocence,’ the hospital can also misrepresent the patient’s condition.
  • Unbundling: 
    • Unbundling is yet another practice similar to Upcoding. In unbundling, every step of a procedure is separated and charged separately. Unbundling results in an enormous bill at the end that the insurance company has to cover. 
  • Falsification:
    • Falsification is when a hospital or a doctor claims that the patient needs a particular investigation or procedure, as it is vital for monitoring health. Falsification is based on false claims. The patient is not in a severe condition, as depicted. The motive is a monetary gain in the form of excessive, unnecessary testing or operation. 
  • Coordinating With the Patients: 
    • In a not-so-formal agreement, the doctor and the patient agree that the patient will get a ‘co-paid’ (both the patient and the insurance company will pay separately) service. 
    • Instead, the hospital would be charging the insurance company without letting them know. This is a two-way approach. It builds patient confidence, and s/he is very likely to return to the same doctor/hospital for his next consultations. 
  • Miscommunication:
    • Miscommunication in health insurance fraud is plain and blatant lying. Health care providers misrepresent the magnitude and cost of a procedure or investigation for monetary gain. 

What’s The End To All This? 

Healthcare Insurance frauds and scams are more common in our society than we think they are. Thankfully, the relevant authorities have become aware of them. Since then, they have made considerable efforts to reduce these heinous crimes. 

HIPAA – the Health Insurance Portability and Accountability Act has recognized this as a severe criminal offence, with the accused being penalized with fines and possibly also serving an 

imprisonment of up to 10 years.

Is this enough?

No, technology will play a vital role. Many tech companies are starting to help in this regard. Datahive Labs has come up with a SaaS-based solution which incorporates conversational AI and Deep Learning algorithms and takes patients/customers on board a digital platform and involves them throughout the process to add another dimension to the data, solving these frauds and mischarges. Our system accurately tags the transactions that involve mischarges, abuses and frauds and put them in the audit category as the insurance is getting approved. This would in-turn reduce the cost of insurance premiums and make the insurances affordable. 

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