Medical insurance fraud is generally defined as knowingly executing a treatment to render medically unnecessary or over-utilizing services that result in useless costs to the healthcare system, including health insurance providers

1. Health Insurance Fraud

2. Medical insurance fraud is generally defined as knowingly
executing a treatment to render medically unnecessary or over-
utilizing services that result in useless costs to the healthcare
system, including health insurance providers
Potential offenders can be - patients, hospitals, doctors,
vendors, suppliers, or even pharmacists

3. If a medical provider encourages the patient to go for
unnecessary tests or treatments, it can pose considerable risk
to the patient's health
Related Figures :
The UAE was losing more than AED 3.67 billion (USD 1 billion) a
year due to health insurance fraud
Over-prescription for medicines and unnecessary tests have
pushed up insurance premiums in the UAE by nearly 20%

4. Precautionary steps that can be adopted for
correction and prevention:

5. Common areas of fraud:
An individual subscriber can commit health insurance fraud
by:
• Allowing someone else to use his or her identity and insurance
information to obtain health care services
• Using benefits to pay for prescriptions that were not prescribed by his
or
her doctor

6. Health care providers can commit fraudulent acts by:
• billing for services‚ procedures and/or supplies that were never
rendered
• charging for more expensive services than those actually provided
• performing unnecessary services for the purpose of financial gain

7. Preventive measures for employers to instruct employees on
how to recognize fraud by medical providers:
• Always keep your health insurance card on you. Immediately report
lost or stolen cards.
• Never sign empty or incomplete claim forms.
• Never sign more than one claim form per doctor per visit.
• Inform your insurer if you do not complete or take any medical
services after pre-authorization.
• Inform your insurer if a medical provider offers to waive your co-
payment or deductible.

8. Problems faced by insurance companies :
• Insurance company have certain guidelines in place to define what
tests you should undergo in certain conditions but healthcare is very
broad.
• Logistically, it is difficult for insurance companies in the UAE to assess
and investigate each claim.
• In 2012, Daman had just 25 employees in its fraud investigation
department and 1,401 medical providers in its health insurance
network in the UAE, resulting in 1.53 million claims processed every
month!

9. Fraudulent claims by employees
More than one laborer who may not have cover, use the same health
insurance card. This is often the case because sometimes no photos are
placed on ID cards, leaving them open to misuse.

10. As the healthcare industry grows in the UAE, the incidence of medical
insurance fraud will also increase.
There has to be firm and intensive efforts by the industry and
regulators to make sure that fraud is eliminated or reduced effectively.
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