JEDDAH: As unfortunate as it is, fraud is becoming a problem in the health insurance sector. Those at fault, local insurance experts say, are usually the private sector health care facilities that resort to such activities to make a profit, leaving unsuspecting patients unaware that they have been ripped off.
According to statistics, health care fraud is one of the main challenges faced by the global insurance market today, amounting to a loss of at least 5 percent of all international premiums with between 6-15 percent of gross claims paid in various countries. Types of global fraud include doctor hopping, denial of pre-existing conditions, misapprehension of facts about illnesses and providers changing treatment descriptions.
The most common schemes found in Saudi Arabia, local insurance experts say, are unnecessarily large-scale orders for medical examinations, such as laboratory tests, MRIs, X-rays and CAT scans.
Another fraudulent scenario is “medication substitution.” Some private health facilities have been caught instructing doctors to prescribe expensive medicines and then allowing pharmacists to switch them with low-cost brands.
Acknowledging that fraud exists in the Saudi market, Mahmoud Awan, corporate marketing manager of BUPA Arabia, said, “The health insurance concept is relatively new to our society. There may be some people misusing it due to a lack of understanding of the process.”
He added that he expects time, information and experience to be involved in the preparation of properly utilizing the benefits of the health insurance system.
Raeed Al-Tamimi, vice president of Tawuniya, told Arab News: “Once a fraudulent act is discovered it will only lead to rejection of the claim and no compensation will be paid out.”
Speaking about measures that Saudi insurance companies follow to cut down on fraud, Al-Tamimi said: “Upon receiving requests for approval or bills from health care providers, our doctors carefully evaluate them. If there is any suspicion, an investigation will be carried out by our Fraud Review Unit.”
However, Awan said one of the first and most important things insurance companies can do in combating fraud is increasing social awareness and opening communication channels between insurance companies, patients and health care providers. “Fraud can be detected at various stages by verification of identity, following international guidelines and transparent communication between the concerned parties,” he said.
Awan said his company was exploring deployment of advanced technology, such as swipe cards and fingerprinting, with an aim to replace current verification and photocopying needs. “The move will considerably cut down waiting time at reception,” he said.
Al-Tamimi said Tawuniya has been able to detect numerous fraud attempts and terminate contracts with some local health care providers who were resorting to fraudulent billing practices.
He pointed out that work is being done to increase the ability of staff by conducting training courses in cooperation with Naif Arab University for Security Sciences in order to familiarize the personnel with the concepts of forgery, kinds of fraud, methods adopted for preservation of records, warranty signs and electronic data, vital standard measurements and combating falsifications.
He said Tawuniya had also begun implementing a rewards mechanism for reporting fraudulent claims.
Nonetheless, Al-Tamimi said with all of these safeguards in place to help combat fraud, the first line of defense in protecting the Saudi market and consumers should be good faith. He also said that insurance fraud is considered a criminal act globally.
