HEALTH/PA & Reimbursement Claim Investigation: 

In health insurance claims, we can check if the person is ill, or whether he’s conniving with the doctor or hospital to get insurance money. Our team can investigate if a disease is pre-existing in the claimant and whether his insurance claims are genuine. Companies also hire us to investigate if someone is showing a different disease to claim money but actually, he has a different disease altogether.

Factual/Circumstance Investigations involve establishing the circumstances of the claim and may vary depending on the desired outcome such as:

• Obtaining the general facts of the claim
• Identification of the negligent party or 3rd party recovery
• General Work Injury Damages inquiries and gathering of processes
• Confirmation of financial records to confirm entitlements

• Commonly occurring frauds in health insurance Health frauds can broadly be divided into- Hard Frauds and Soft Frauds. Each of these broad categories further constitutes of situations ranging from misrepresentation of facts to fabrication of documents, and even situations including inflation of claims. Hard frauds usually involve a more extreme form of activity such as the absence of a patient in case of situations involving hospitalization, in the first place.

• Misrepresentation of facts: Perhaps one of the largest types of fraud, a case qualifies as misrepresentation when the insurance applicant is completely aware of the inaccuracy of the statement/information provided. Amongst the most commonly falsely stated details are details regarding medical conditions or diseases, incorrect personal details such as name, age, identity, etc., or even information such as medical history, past claim information, and soon.

Fabrication of documents: It is commonly noticed that the fabrication of documents often acts as a frequent form of fraud-related activity that the health insurance industry is faced with. These documents could range from those regarding medical details/history of the insured, or documents at a later stage such as claims related or other documents such as fake letterheads. Forgery of medical bills and receipts is yet another increasingly rampant issue in health insurance fraud.

 Inflation of claims: Another frequent occurrence in the domain of health insurance is that of inflated or exaggerated claims. It is not rare to come across the assumption/belief by customers that the insurance company invariably refuses to pay the complete claim amount as put forth by the customer/policyholder. This seems to be a common motive for several customers to present an exaggerated claim amount by false methods, for their monetary gains. However, it can be said that frauds of this kind are relatively easier to detect and investigate.

• Prevent
  our team takes a keen interest in the process followed for all fraud-related investigations to ensure the authenticity of the case. These investigation methods involve extensive procedures irrespective of the situation, be it a cashless case or even one involving reimbursement.

To identify the possible fraudulent cases based on certain triggers. The module also makes the entire process more efficient, as it is all taken care of by an automated process, as opposed to the previous manual processes followed for the same.”

Health Insurance Claims

False Claims- Fraudulent Claims for medical services or treatments which were not provided.

Identity Frauds-  Non-insured Person “A” File a health claim on the health policy of a person “B” by providing personal details of the Person Staged Accident- Fraudster organizes accident to file fraud for medical expenses.

Cuts in Referral Fraud: some health care providers may offer cuts or commissions in exchange for referring patients or prescribing specific medications.

Underwriting-Operational Frauds in Booking of Business.

Covering Pre-Existing Loss. Back Date Policy Booking. (Misuse of Proposal Forms/Cover Notes/Backdated Cheques) Premium Siphoning. 

Short Premium – Insuring vehicle in wrong Category (Commercial Vehicles policies were booked under Two Wheelers policies)