5 ways Aetna International tackles dishonest activity to pass on savings to members

Tackling fraud, waste and abuse

Aetna International is proud of its global reputation as a market-leading international private medical insurance (iPMI) provider. We work hard to provide our customers with the health and wellness support and reassurance they deserve. Rising costs are driving inflation in the medical provision sector, and with it member premiums. This rise is driven by a number of factors including lifestyle choices, regulations that transfer the burden of costs to private plans and foreign exchange rates. In 2015, this rate was 8.75%, 5.5 points higher than retail inflation across the globe. And it is set to rise.

With this in mind, it’s reassuring to know that Aetna International aims to protect its members and customers from unnecessary premium increases. This includes taking a strong, tactical approach to cost containment across all our business functions, including the way we tackle wastage and fraud. Using analytical software and specialists, training and research, along with old-fashioned intuition, experience and leg-work, we demonstrate how to stay ahead of the game — and how our members, individuals and organisations alike, benefit from these savings.

1. Health care fraud
   It’s estimated that global health insurance fraud costs health care providers an astounding U.S. $ 260 billion per year. “We have a dedicated investigations unit, made up of accredited health care fraud investigators and analysts”, explains Jim Stedall, Senior Director of Global Business Delivery and Head of Claims and the International Special Investigations Unit (ISIU) at Aetna International. Having a respected and industry-savvy network of experts, with pre-set policies and procedures to follow, means we can consistently cross-reference cases, keep an eye on trends, and keep fraudulent activity in check. 
   
   
2. Tackling false claims
   Fraud includes misrepresenting, deceiving or concealing information for financial gain and can take our specialist teams months or even years to uncover and resolve. But it’s worth it. Flagged up as suspicious by the claims team, a recent claim worth $20,000 U.S. dollars was passed to our International Special Investigations Unit (ISIU). Expert eyes soon exposed the paperwork as fake and our comprehensive network revealed links to another fraudulent claim in Argentina. An established relationship with the hospital in question confirmed the claimant neither received treatment or made any payment. The result? Aetna International denied the claim and terminated the policy. The work of our innovative, creative and knowledgeable teams is focused on getting results.
   
   
3. Making the right connections
   Being part of a wider network ensures we can plug any gaps in our processes, nipping fraud, waste and abuse in the bud before they become a problem. “We have dedicated Fraud Champions within our claims teams around the world, who attend monthly calls and are updated on the latest scams and FWA (fraud, waste, abuse) in their region”, Jim Stedall continues. This information is then cascaded down to their teams so everyone is in the know. Having a wider view and a keen approach to targeted training, means we have the necessary background information on what to look for, what the trends are and how to deal with them.
   
   
4. Targeting abuse
   “We also carry out regular data analysis looking for trends at a member or provider level and, when identified, these are referred to the investigators.” Jim demonstrates how an across-the-board approach and access to a huge amount of data are part of the strong commitment we have to making sure our customers’ premiums are used in the right way. It’s a matter of having the systems in place to get the information we need, and then having the power and experience to pursue abuse of funds, wherever we find it. For example, when someone’s claim or claims reach a certain threshold, this can trigger a referral, to ensure funds aren’t misused and honest clients get the level of cover they’ve paid for. We also apply sanctions on proven FWA cases including recoveries of paid claims and non-payment of claims, criminal reporting and legal action.
   
   
5. A world-wide approach
   Taking a global approach means working with other international organisations to protect our members’ premiums, Jim Stedall explains. “We are members of the European Healthcare Fraud and Corruption Network (EHFCN), as well as other fraud entity bodies around the world such as the U.S., Canada, and South Africa.” Operating at an international level, we are respected experts in our own right, present at global fraud summits and working with other fraud-preventing bodies.
   

Through a number of agencies: both human and technology-based, we share and analyse data to ensure we pick up and act on fraud, abuse and wastage as soon as we can. Underpinned by a respected network of relationships across hospitals, professionals in the anti-fraud sector, and investigators right down to ground level, our teams work hard to save money for our members by keeping premiums where they should be and our customers — from organisations with a multinational workforce to individuals - happy. We’re also committed to proactive measures, embracing innovative new tools and generating bright ideas: keeping health at the heart of everything we do.

To find out more about our cost containment measures (action we take to try and keep costs down) and the many ways we keep premiums in check, including proactively outreaching to eligible members to prevent and manage chronic conditions, contact one of our expert consultants in your region.

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