Healthcare industry is a booming sector in India and it is also replete with various challenges. Health insurance policies are designed with the intent of providing medical aid smoothly. It is equally vital to understand the health insurance details to gain optimum coverage.
However, the past decade has witnessed a rise in the fraudulent claims made by individuals. There is a constant need to revise the health insurance details, to avoid such deceitful claims. Both the insurance companies and policyholders must work together to tackle the problem.
Let us begin by first understanding the types of frauds in health insurance.
DIFFERENT TYPES OF HEALTH INSURANCE FRAUDS IN INDIA
• Opportunity Fraud: This occurs when the policyholder provides inaccurate information while making a claim. One can hide a pre-existing condition or mislead the insurer to get the underwriting in their favour.
• Deliberate Fraud: This involves the deliberate presentation of an accident or damage that is covered under the policy.
• External Fraud: This is the fraud committed by policyholders, beneficiaries, medical service providers or vendors against a company.
• Internal Fraud: This is the fraud committed by agents, managers or executives against a company. Even a policyholder can be at the cheating end of it.
• Policyholder’s Fraud: It basically comprises the below-mentioned 3 types of frauds – claims, eligibility and application.
• Claim Fraud: Of the various other health insurance frauds in India, this is another one. Under this, the person can make an illegal claim to take advantage of the insurance coverage.
• Eligibility Fraud: This is one of the many frauds in health insurance. It occurs when the person fills in incorrect information regarding the pre-existing condition or employment status.
• Application Fraud: The concerned individual can enter wrong information to avail the extensive coverage.
STRICT MEASURES TO COMBAT FRAUDS IN HEALTH INSURANCE
Health insurance frauds in India can be checked by analysing the fallacious behavior of frauds. Certain measures have been put in place to deal with health insurance frauds in India.
• A strict screening process is implemented by various insurance providers in India nowadays. Many insurance companies are leveraging technology to detect fraudulent behaviour. In order to mitigate risks that threaten the healthcare industry, one must harness technical tools. Regions that show a higher tendency towards such cases are under high scrutiny.
• In recent years an emphasis has been made on establishing a standard reimbursement procedure. This can pave the way for ease of claim settlement. Healthcare providers should abstain from overcharging, holding back patients and ordering unwarranted tests.
• No room should be left for error by doing things manually. One can detect fraud by taking the help of data analytics. Insurance providers can frame predictive models and infer useful information from a data analytics tool.
• In today’s digital era, one can optimally utilize technology and big data to trace fraud. This way insurance company can stay one step ahead of their problems.
• The health insurance details must be scrutinised both by the policyholder and policy provider. A proper understanding of the health insurance details can eliminate customer confusion. This can lead to healthy correspondence between the provider and the recipient.