What brokers gain from Aetna International’s war on health care fraud

Heath care fraud is one of the most significant financial threats to businesses in the industry.

It is a worldwide threat to the development of medical services, the provision of resources, and health care funding.

Health care fraud is estimated to cost $1.1 trillion worldwide. Standing at a cost of $272 billion in the U.S. alone, health care fraud is a very real concern for all medical industry and service providers.

Health care fraud — inside the threat

Health care fraud is an umbrella term for the many schemes, behaviours and deceptions aimed at deceitfully gaining financial benefit through the health care insurance system. Health care fraud can be committed by any individual in the chain: be that the medical professional billing the treatment, the policy member, their family or friends, or the staff involved in treatment provision. The total cost of international health care fraud is consistently estimated in excess of 10 percent of overall health care spending. With this type of fraud on the rise, the fight against it has never been more imperative.

The depth of the problem is best understood when looking at the sheer volume of different methods and fraudulent activities facing the medical profession. Health care fraud can come from an individual acting alone and falsely claiming for a non-existent treatment or for an undisclosed previously existent condition. These claims alone can cost in the tens of thousands of dollars per individual.

There are then the collaborative scams, whereby individuals or groups work to fabricate medical activity, illness and prescription medications. These choreographed activities either use incentivised individuals who submit fraudulent claims, or occur through the use of stolen identities: stolen identity-based health care fraud alone amounts to 450 U.S. cases per day. There are also fraudulent practitioners who inflate claims, invent prescriptions, and reuse or incorrectly distribute medication for financial gain.

Aetna's international allegiances

This cost is directly affecting international health care budgets: these additional costs cut directly into the care budgets and can cause premiums to rise. The United States health care industry has been hit hard, with costs directly affecting the insurance providers, brokers and end-users equally. At Aetna International, we have a taken a stand against this criminal subculture exploiting the industry. We have a zero tolerance stance against fraud of all kind.

Our parent company, Aetna Inc. has a strong relationship with the Federal Bureau of Investigation (FBI) in the United States, which has led to such successes as reclaiming $7.8 million from a fraudulent individual following an FBI investigation. At Aetna International, we can coordinate with our Aetna counterparts who handle in U.S. domestic private medical insurance fraud for insight on international cases. The success of this relationship bolsters our international commitments to cracking down on fraud.

Aetna International is a contributing and active member of European Healthcare Fraud & Corruption Network (EHFCN), developing our own structure for detecting fraud on the basis of the Operational Sub-Committee (OPSC).

The EHFCN, founded in 2005, works to facilitate a European framework for the detection, prevention and sanction of fraudulent crime. The committee has created a culture of anti-fraud business practice and policy, encouraging industry and international state co-operation.

Working within the structures set out by the EHFCN, Aetna International has established an advanced and systematic fraud detection unit, working with our partners to share the information gathered. Our in-house specialist counter-fraud department has direct working links with EHFCN, enabling us to notify them of schemes and patterns, and the people responsible for them.

Fighting the fraudsters

Information sharing is key to staying ahead of fraudulent trends and developments. It works to keep all iPMI and health care providers abreast of large-scale and highly developed fraudulent schemes. Aetna Inc.'s involvement has helped to detect and prosecute in a variety of cases, including one organised activity concerning a kickback and billing scam, which resulted in a $37.4 million award to Aetna Inc. This 2016 case involved a group of medical practitioners who had structured a system of overbilling. The scam, where the same individuals targeted Aetna Inc. and four other health care providers, was detected following a 2014 investigation. With such high sums at stake, an aggressive strategy and active involvement in international detection is key.

Here are just some of the ways we're keeping fraud at bay.

• We train all our expert sales consultants, health care affiliates and internal staff in detection, patterns of behaviour and how to spot red flags.
• If there's a cause for concern, our consultants refer cases to our in-house fraud detection agency, the International Special Investigatory Unit (ISIU). This 100-strong team uses advanced technology, data sharing, and specialised computer programs to tackle fraud head-on.

Our cutting-edge training and specialist resources are key to detection, as made clear in a 2016 case referred to the team. Local expertise and language specialists enabled the ISIU to detect a $20,000 false claim in Brazil. This resulted in the refusal of payment for a false hospital stay, as well as complete revocation of membership and policy for the individual. Individuals found to have committed fraudulent activities are then put on file for internal and external sharing in an attempt to prevent repeat offences. A comprehensive data capture system and specialist technology allows the team to spot anomalies and investigate any suspicious claim or behaviour. Using a six-stage prevention, detection and compliance procedure, the thorough and intensive work of the ISIU team saves Aetna Inc. $200 million a year.

Supporting our contemporaries

As a market-leading international private medical insurance provider, we have access and membership to exclusive organisations. Our success in implementing anti-fraud measures is only successful if all links in the chain are working towards the same goal. It is imperative that we support others who provide health care insurance so we present a united front against health care fraud.

Our small business consultants and partners pass on knowledge from the training and support we benefit from as a member of international organisations, to our clients. Referrals to the ISIU and information sharing are also encouraged and supported.

What does this mean for you?

Our highly developed system translates to real prevention, detection and results: these savings are passed on to our brokers, clients and members through maintaining lower premiums. Less money wasted on fraudulent claims every year means that we protect our company profits and stand a better chance of keeping premium inflation in check.

In addition to the financial benefit of health care fraud reduction, our proactive approach protects all those involved from identity fraud, keeping our customers and partners safer. Our additional efforts mean that you can be assured that you are providing your employees with a market-leading insurance package, bolstered with ongoing care and attention to meet the interests of members and stakeholders alike.

To find out more about how Aetna International is protecting our customers and partners from health care fraud, contact our expert sales consultants today.

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