Medical Insurance and Fraud

Transcription

1 Session: Medical Insurance and Fraud

2 Consultant Salah Al Halyan GIC Founder and Director 28 years experience in the field of Insurance United States of America Licensed from States of California & Florida Life and Disability, Property, Casualty, Medical and Investments United Arab Emirates Insurance Consultant Insurance Expert and Arbitrator: Dubai, Abu Dhabi Courts and Ministry of Justice UAE s leading Financial Literacy Expert, founder of Baizat and Baizati Training Institute

3 Introduction The Cost of Insurance Fraud The Coalition Against Insurance Fraud estimates approximately $80 billion in fraudulent claims are made annually in the United States, across all lines of insurance. Healthcare fraud alone is estimated to be $54 billion a year.

4 Introduction The Cost of Insurance Fraud People can lose life savings through insurance investment schemes Lives at risk due to doctors/health care professionals performing unneeded services to illegally inflate insurance claims Sky rocketing premiums as insurance companies pass cost of fraud to policyholders Higher inflation as businesses pass greater cost of health and commercial insurance onto customers Businesses lose significant annual income as fraud increases their employee health coverage and business insurance costs

5 Parties of Health Insurance Insurance Companies Third Party Administrators (TPAs) The Insured Individual Corporate Association Health care providers Hospitals Clinics Pharmacies Medical Laboratories

6 Overlook Private Health Insurance Benefits Exclusions What s payable by the policy Policy wording the contract The Application Expenses control Health Care Claims Prices of medical insurance

7 Financial Crimes Identity Theft Using someone else s personal information for financial gain Wrongfully obtaining names, addresses, birth dates, social security numbers, and bank account numbers of victims. Using the info to open credit card accounts, apply for loans, or open bank accounts. Number of identity theft complaints in US from

8 Financial Crimes Medical Identity Stealing a consumer s personal information to lodge fraudulent claims against the insured s health policy: Incidents increased 21.7 percent in 2014, 2.3 million Americans affected in 2014; 65% of victims paid average of $13,500 to resolve the crime; Victims learned their medical identity was stolen an average of three months after the incident; An average of 200 hours taken correcting their compromised data

9 Insiders caused 43 percent of breaches Financial Crimes Cyber Attacks Healthcare breaches remain a major problem affecting millions of Americans annually: On average one health data breach a day recorded in in total and more than 27 million patients affected

10 Financial Crimes Credit Card Fraud Using someone else s card to make purchases without their permission. In 2016, worldwide losses from credit card fraud topped $24.71 billion (Nilson Report) Approximately 65% of the time, credit card fraud results in a direct or indirect financial loss for the victim (CreditDonkey.com) 46% of Americans have had their card information compromised at some point in the past 5 years (ACI Worldwide)

11 Insurance Fraud costs the average U.S. family between $400 and $700 per year in the form of increased premiums (FBI) Financial Crimes Insurance Fraud Reporting an incident that did not occur to an insurance company - auto, home, health, workers compensation - with the intention of collecting money on the claim Exaggerating claims to get a larger pay-out Unscrupulous doctors, medical professionals, or lawyers billing insurance companies for tests, X-rays, and office visits that never even took place

12 Financial Crimes Health Care Fraud Wrong Billing: Tests, Diagnosis, Services and Medicine Misstatement of Services or goods provided Inflated Rates Healthcare organizations infamous for charging unreasonable rates Unnecessary Treatment (eg MRI Scanning) Some providers have even combined personal expenses with Personal Expenses their claims for medical care

13 Financial Crimes Detecting and Reporting Fraud Know who you are dealing with and why Safeguard your info Check with your insurance provider Be sure of your online contact Always be aware of potential fraudulent activities when dealing with medical providers via the Internet and during their normal daily

14 Financial Crimes Civil Litigation in Claims Fraud Nature of cases and time taken Get an experienced lawyer in medical insurance and health care litigations Take a professional advice from insurance expert Read and understand your insurance policy and coverage

15 Thanks for your time Any questions? Follow me on Or drop me an