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Aetna International Combatting Fraud, Waste and Abuse in Health Insurance
Aetna International’s International Special Investigations Unit saves and recovers more than $3 million USD related to fraud, waste and abuse a year, helping to keep costs and premiums down
May 25, 2018 — Global health care benefits provider Aetna International has launched a new report investigating the cost of fraud, waste and abuse on the health care industry, which costs the sector tens of billions of dollars every year. Combatting fraud is of huge importance to Aetna International so that care, money and resources go towards improving global health whilst also keeping individual premiums down.
The report identifies how Aetna International’s International Special Investigations Unit (ISIU) is leading industry efforts to combat fraud, waste and abuse, saving and recovering more than $3 million USD every year to the benefit of its 800,000 members. This is in addition to the tens of millions of $USD in savings and recovery made from parent company Aetna Inc, which has more than 49 million members*.
The findings highlight that fraud, waste and abuse are often allowed to continue because many believe fraud is a victimless crime. The reality is that fraud leads to increased costs for health care systems and providers, and International Private Medical Insurance (iPMI) partners as well as increased premiums for individuals and organisations. The potential perpetrators of fraud are varied and can range from brokers, to hospitals, to members, to scammers.
The report also highlights some frequent indications of fraud, such as misspelled or misused medical terminology on claims forms, alterations on claims submissions or enrolment forms, or high incidences of prescriptions that do not coincide with medical claims histories, It is hoped that this will encourage employee benefits and wellness managers and individuals who hold IPMI plans to remain vigilant to possible fraudulent activity and help the industry to combat fraud.
To detect fraudulent activity, Aetna International uses its proprietary technology and harnesses its vast amount of data, with advanced business intelligence software to identify providers whose billing, treatment or patient demographic profiles differ significantly from those of their peers. Aetna International also enlists members and providers in helping to combat fraud by educating them and publicising high-profile cases.
A 2017 review of claims enabled Aetna International’s ISIU to identify a member involved in fraudulent activity costing $450,000 USD, leading to legal action and the recovery of funds.
Steven Knox, Manager, ISIU, Aetna International says: “At Aetna International, we have a zero-tolerance approach to fraud. Our International Special Investigations Unit works closely with the European Healthcare Fraud & Corruption Network (EHFCN) to combat criminal behaviour that negatively impacts businesses and their employees. It is imperative that organisations and employees alike are equipped with the knowledge to identify and report and act upon fraudulent activity.”
Aetna is a member of the EHFCN, collaboratively working to prevent and detect fraud within the health care insurance industry, and vigorously pursuing anyone involved in suspicious activity.
* As of December 31, 2017: Medical Membership: 22.2M; Dental Membership: 13.4M; PBM: 13.8M
Further reading
- Bending the curve: Tackling fraud, waste and abuse
- What brokers gain from Aetna International’s war on health care fraud
About Aetna International
Aetna International is committed to helping create a stronger, healthier global community by delivering comprehensive health care benefits and population health solutions worldwide. One of the largest providers of international health benefits and services, Aetna International serves more than 800,000 members worldwide, including expatriates, local nationals, and business travellers. Its global benefits include medical, dental, vision and emergency assistance and, in some regions, life and disability. Aetna International also offers customised technological and health management solutions for healthcare systems, government entities, and large employers to improve people’s health, enhance the quality of care and contain costs. Employers and brokers can find out more about our services by contacting an expert advisor in their region.
About Aetna
Aetna is one of the leading diversified health care benefits companies in the U.S., serving an estimated 46.7 million people with information and resources to help them make better-informed decisions about their health care. Aetna offers a broad range of traditional, voluntary and consumer-directed health insurance products and related services, including medical, pharmacy, dental, behavioral health, group life and disability plans, and medical management capabilities, Medicaid health care management services, workers' compensation administrative services and health information technology products and services. Aetna's customers include employer groups, individuals, college students, part-time and hourly workers, health plans, health care providers, governmental units, government-sponsored plans, labor groups, and expatriates. For more information, see http://www.aetna.com/ and learn about how Aetna is helping to build a healthier world. @AetnaNews.
