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Fraud prevention

Insurance fraud is not a victimless crime

Many believe that insurance fraud is a victimless crime. The reality is, left unchecked, insurance fraud can lead to increased premiums for members and organisations, as well as increased costs and financial losses for health care systems and providers.

Fraud, waste and abuse corrode trust. They waste time that could otherwise be spent on the betterment of the industry and improving health care outcomes for individuals. When it goes unchallenged, insurance fraud creates a lose-lose situation, and everyone ends up paying eventually.

Other mistaken beliefs held by industry professionals and individuals alike include: 

  • Health services should be provided at any cost
  • More care and treatment are always better
  • Expensive care and treatment are always better
  • The professional integrity of health care providers cannot be challenged 

Read on to find out how we help to keep your identity safe and your costs as low as possible. 

Fraud, waste, and abuse explained

There are many ways that fraud, waste, and abuse can occur and many perpetrators including medical providers, brokers, insured members, employers, scammers and criminal networks.

Around the world, fraud can be defined differently by law, compliance and fraud regulators. But, in the simplest terms, it’s about intent. If someone intends to manipulate or exploit a claim to financially benefit or profit in any way, it’s fraud.

Fraud can include: providers overtreating unnecessarily or billing for legitimate treatment using a different diagnosis; members submitting false medical claims where no medical treatment has taken place; systematic, repetitive mistakes; or opportunistic exaggeration of circumstances.

Safeguarding you from fraud 24/7

Our actions to protect against fraud, waste and abuse contributes to millions of dollars saved per year. This helps us combat medical inflation and keep premiums in check for the benefit of our members, customers and brokers.

Following our partnership agreement with Allianz, we now have even greater resources and capabilities at our fingertips.

We employ both human ingenuity and advanced data analytics to successfully tackle fraud, waste, and abuse. The key is strong internal governance. This involves efficient, accredited anti-fraud processes; rigorous training of frontline staff and special investigators; and regular support from fraud experts.

Our rigorous approach to fraud, waste and abuse involves:

1.       Proactivity — Our teams work closely with our provider network, carrying out regular audits, updating counter fraud processes, employing investigative interview and research techniques and baking fraud governance into the design of products. It’s about teamwork and collaboration.

2.       Pursuit — Our International Special Investigations Unit (ISIU) vigorously pursues those involved in suspicious activity. We devote the time and resources necessary to tackle fraud, waste and abuse, to deter fraud and to help protect our members, our customers and ourselves. Our global experience is backed by local experts around the world who provide regional insights to support reviews and investigations. We also work closely with local law enforcement and legal representatives to track down and prosecute those who engage in fraudulent activity. Our relationships with law enforcement, legal entities and counsel reaches around the world to help us find offenders and bring them to justice.

3.       Collaboration — We have extensive anti-fraud networks dedicated to preventing and detecting fraud within the health care and insurance industries and we also collaborate with other fraud entities and agencies around the world.

4.       Expertise — Our ISIU is repeatedly called upon by our industry peers and broker partners to consult our live cases and FWA processes. By sharing our expertise, we enable others to pursue their own investigations more effectively

5.       Results — Our efforts help keep premium increases low, helping to contain costs for our customers and to protect the wealth of our members.  

Advice for our members

Apply the following logic and guidance to help keep your identity safe and your premiums low: 

  • Protection — Protect your health insurance membership or ID card as you would a credit card. Keep your policy number and personal insurance information private on the phone and internet. Be careful about disclosing your information.
  • Report — If you suspect you may be the victim of identity theft or insurance fraud, call us. Medical identity theft is on the rise. Thieves use personal health insurance information to steal expensive medical services, equipment and drugs.
  • Diligence — Keep a close eye on your medical reports, the services and invoices you receive, and all your medical care records.
  • Informed — Read your policy, benefits statements, your Explanation of Benefits (EoB) statements and any paperwork you receive from your insurance company carefully. Make sure the treatment dates, details, charges and expenses are correct to the best of your knowledge.
  • Integrity — Be aware that sharing medical coverage with uninsured family members or friends is against the law. This can lead to tainting electronic medical records and incorrect diagnosis for the insured, among other negative fallout.
  • Eyes open — Be wary of offers for ‘free’ health care services, tests or treatments. These could be fraudulent schemes designed to bill you and your insurance company illegally for thousands of dollars you have never received. 
Advice for our customers

Apply the following guidance to your best-practise internal policies and procedures to help keep your members safe and your plan costs in check:

  • Protection — Protect your policy information. Be careful about disclosing any policy or group scheme information over the internet or phone.
  • Education — Inform your employees of the impact of FWA, which increase the cost of providing health insurance benefits and put company and government schemes at risk. Refer employees to further reading, such as an Aetna member handbook which outlines the implications and costs of health care fraud, waste and abuse.
  • Diligence — Select your broker partners and health insurance company with care. Ask questions about their FWA processes and policies.
  • Report — If you suspect your organisation may be the victim of insurance fraud, call your insurance company.
Share your concerns and seek advice

Members: If you suspect fraudulent activity or identity theft in relation to your company plan or personal information, contact your HR department, plan sponsor or call the number on the back of your Member ID card and ask to speak to the Member Services Team (MST). The MST will be able to give you further information or guidance.

Plan sponsors: If you suspect fraudulent activity or identity theft in relation to your corporate scheme or an individual member’s plan, contact your account manager. Your account manager will be able to give you information or guidance or connect you with the International Special Investigations Unit (ISIU). 

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