Health insurance fraud has become a huge problem for the global insurance industry. It is the most complex and challenging problem to combat of the insurances under Global Insurance Fraud Education (GIFE). The industry is confronted not only by the devices of the claimants themselves but also, most challenging for them, fraud perpetrated by physician providers around the world. An example is the e-mail below shared by a Special Investigator, Special Investigation Unit (SIU) of a major Canadian insurance company on May 31, 2014.
Health Insurance Fraud
“One of our competitors paid our policyholder $3000 for a claim that took place in 2013 for malaria, different medical facility.
The Claims Manager didn’t know that doctors around the world write fraudulent medical documents, nor did they have an idea what the usual and customary rates would be in third world countries.
I hate to think of how much money they threw out the window over the years.”
As usual, in the article, the first country in Capitals denotes the country where the claim originated. The second country is the location of the insurer.
Breast Augmentation or Injuries!
ARGENTINA / UNITED KINGDOM – It appeared difficult to believe that for a non-life-threatening condition, the surgeon was in such a hurry that he could not schedule the surgery for another day. Further, it was incredulous that he was able to engage the services of the Anesthesiologist and contract the use of the hospital’s operating theater, all on this first visit.
Canadian Insurer paid USD12,000 for treatment of USD35!
SIERRA LEONE / CANADA – If insurers do not develop a zero–tolerance attitude towards combating fraudulent claims, they will certainly continue to be taken for a ride. Adopting this stance is, however, dependent on insurers’ Claims Examiners or Special Investigators imbibing relevant fraud knowledge as it cannot be sustained in an atmosphere where lack of knowledge persists.
MRI and X-Ray billed the same charge, USD440!
THAILAND / UNITED KINGDOM – Second, the amount allegedly charged for MRI of the right knee, USD440, was the same charge (USD440) for an X-Ray examination of the right knee! This is an anomaly because the X-Ray charge is usually far less than the charge for the MRI. This, therefore, places a huge question mark whether the invoice is indeed authentic.
Insights into fraud from Europe (2)
EUROPE / GLOBAL – However, the clinic existed, but the physician in charge informed us that she had co-signed the claim documents when a man presented them to her and requested her to sign them! She confessed that the policyholder was neither hospitalized nor treated by her. She insisted that she had only appended her signature in the documents he gave to her as a favor and no more. Although she denied it, but it was apparent that she signed the document for a fee.
Serial fraudulent claimants (5) / Kenya
KENYA / UNITED STATES – Most of the clinics are managed by persons who are not physicians. They are those who have only three years of medical education. They are then awarded the Diploma in Clinical Medicine following high school education. The holders do not usually go further to complete a full medical course and to obtain a medical degree. The holders of the diploma are called Clinical Officers (like Medical Assistants) and they are not physicians nor medical doctors.
Serial fraudulent claimants (4) / Italy
ITALY / CANADA – Greedy fraudulent health insurance claimants do not simply walk away when caught. Even when each claim is investigated and found inauthentic, they do not stop filing such claims. What they do is to forego the emergency medical expenses policy and take another policy or series of policies with other insurers. They only hope that one or two of the insurers would not seek on-the-spot investigation and opt to pay the ‘benefits’ straightaway.
Insights into fraud from South America (2)
SOUTH AMERICA / GLOBAL – Our on-the-spot inquiries and investigations at the hospital in Peru revealed that the policyholder’s name did not appear in the hospital’s patients’ register. The alleged attending physician initially said that he hospitalized her, but later told us that he treated her in the hotel room. Yet, much later, he confessed that there was no treatment at all and that he had fabricated the documents presented to the Canadian insurer. This was a Category ‘C’ Fraud, that is, fraud perpetrated by the policyholder in connivance with the physician.
Serial fraudulent claimants (3) / India
INDIA / UNITED STATES – One other red flag was that the physician’s qualifications were depicted as MB, BS., FRCP (Surgery). While MB, BS which stand for Bachelor of Medicine; Bachelor of Surgery degrees are authentic medical qualifications, FRCP (Surgery) is not a medical qualification awarded anywhere in the world. We know that FRCP stands for Fellow, Royal College of Physicians. Medical practitioners who hold fellowship qualification in surgery are awarded the FRCS, that is, Fellow Royal College of Surgeons and not FRCP (Surgery).
Fabricating documents of existing medical providers (1) / Russia
RUSSIA / UNITED KINGDOM – This claim originated in Russia but was filed with an insurer in the United Kingdom. The policyholder, a United Kingdom permanent resident, traveled to the Russian Federation on holidays. On his return to the United Kingdom, he filed a claim that he had been hospitalized and treated for “cerebral concussion, multiple contusions and scratches of the extremities and back” at a private clinic in the city of Vladikavkaz.
Insights into fraud from Asia (1)
ASIA / GLOBAL – India and Pakistan are the two major countries where fraudulent foreign health insurance and medical expenses claims originate predominantly in Asia. We have investigated hundreds of claims in India for insurers, Health Maintenance Organizations (HMOs) and travel insurance companies in the United States, Canada, and Europe in the last one decade. We found out that only two of the cases were authentic while the rest fell into the three main categories of fraudulent claims.
Serial fraudulent claimants (2) / Cameroon
The alleged attending physician provided the insured with a medical report wherein he spelt check the American way. Cameroon is a bilingual country (English and French are spoken). Check is usually spelt the British way, that is, Cheque. Also, there were repeated use of words alien to Cameroon, such as combo (usually an American jargon).
Insights into fraud from South America (1)
SOUTH AMERICA / GLOBAL – Our inquiries and investigations in Chile revealed that the alleged attending physician was a plastic surgeon and that the policyholder had undergone plastic surgery; namely, liposuction of the trunk/waist and breast implant/augmentation (cirugia plastic implante de mamas). We further found out that the physician did not perform surgery for hernia.
Serial fraudulent claimants (1) / Bangladesh
BANGLADESH / UNITED STATES – We also found out that the telephone number in the claim documents did not belong to the hospital. It belonged to the alleged attending physician and was a land line fixed in his consulting office. The physician has no relationship with the hospital and does not even consult there. The hospital’s authentic telephone numbers were entirely different, and none was the number stated in the claim documents.
Insights into fraud from Africa (1)
AFRICA / GLOBAL – Nigeria and Cameroon form the “Siamese twins” in respect of fraudulent health insurance claims filed with overseas insurers. It is difficult determining which country trumps the other in volume as well as in complexity. In both countries, over 60% of the claims investigated every year involves those in which the physicians connive with the policyholders to contrive treatment documents when no hospitalization or treatment took place.
Man, in casts!
TOGO / UNITED KINGDOM -What you see in the picture (right) is the unprofessional act of an unscrupulous medical practitioner in Lomé, Togo, West Africa. The man in the picture, a United Kingdom (UK) resident traveled to his country of origin, Togo, to visit his extended family and friends. He approached a physician and convinced him of his intention to defraud the United Kingdom insurer. The physician agreed and proceeded to place him in leg and arm casts! The man took photographs, grimacing from ear to ear, in pseudo pains.
Insights into fraud from Europe (1)
EUROPE / GLOBAL – Bodrum, a port city in the Mugla province of Turkey is a tourist vacation hotspot for Europeans. It is, therefore, not strange that as in such cities around the world, it has its own share of unscrupulous physicians and providers who collude with tourists to contrive medical documents which they present to their insurers on return from their overseas trip.
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