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Tackling fraud: Changing perceptions of the health insurance industry

Perceptions of health insurance fraud are slowly changing for the better as people begin to better understand the link between fraud and premium increases.

This was the key message from Steve Knox, Aetna International’s lead fraud investigator and International Special Investigations Unit manager at a recent worldwide industry conference.

Knox joined Phil Peart, General Manager, Travel Claim Investigations for MJM Corporate Risk Services, and Ingenin CEO Ranjit Mana in Geneva, Switzerland, in late October at the International Travel Insurance Conference (ITIC) Global 2018 to discuss the latest trends in fraud and best practices to combat it.

Fraud can take the form of amended receipts and claims forms, images and reports pulled from online sources and submitted as legitimate documentation, dual claims, collusion with unscrupulous health care providers, and the sharing of membership cards amongst friends and family.

"While only a small number of our 800,000-strong member base commits fraud, they generally fall into two categories: opportunistic fraud and cases where the plan is solely taken out with the intention of committing fraud," said Knox.

He noted that the historic perception of the health insurance industry as ‘fair game’ when it comes to fraud and abuse has been changing lately.

"The impression used to be that because individuals pay for their insurance cover year after year — often without needing to claim — they should be entitled to recoup some of that, and that it’s okay to fudge a claim now and again,” he said. "But sooner or later, the damaging effect of fraud is felt by everyone from members to providers whether they realise it or not."

For employers and members, fraud impacts their wallets and well-being by pushing up health care inflation and premiums and affecting their wealth and associated happiness.

For providers and payers, it puts pressure on their finances by squeezing budgets that should be allocated to innovation in service and technology — much of which is designed to keep people well, improve their health outcomes and rein in spiralling health care costs.

"Although some people mistakenly believe the chances of being caught are low and the repercussions minimal, it's becoming less 'socially acceptable' to wantonly commit opportunistic fraud," said Knox. "And it’s becoming less acceptable for organisations to 'farm claims', where managers and intermediaries encourage people to make insurance claims. People now understand that fraud results in a lose-lose situation — and that’s one of the reasons why we have a zero-tolerance policy at Aetna International."

Knox shared valuable insights at the conference on the lengths to which Aetna International goes to prevent fraud, waste and abuse and recover misappropriated funds.

"There aren’t many examples of fraud that our claims teams haven’t experienced," he said. "With data mining and other robust fraud prevention procedures in place, strong collaboration across key organisational departments, and the expertise and language skills of our regional experts, we have a strong track record of preventing and detecting fraudulent activity. We also maintain close ties to national and international crime agencies to whom we report the names of perpetrators."

Understanding there may be instances where errors are the genuine result of forgetfulness or misinterpretation, Knox said that it’s important to look into every questionable claim with a close eye. "Not all fraud is committed with malicious intent," he added. "But we investigate all claims that raise red flags to determine whether deliberate fraud has occurred, at which point action can be taken and the claim is denied."

For more information on Aetna International’s approach to fraud, waste and abuse — one of our core cost containment strategies — please contact your sales or account manager.

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