Controlling fraud and abuse in health insurance Investigating agencies perspective

1. Dr. Rajendra S. Bangal MBBS, MD (Forensic Medicine), DNB (Legal Medicine), LL.B. EXPERT MEDICOLEGAL CONSULTANCY PVT. LTD. Controlling fraud and abuse in health insurance Investigating agencies perspective

2. ROAD BLOCKS IN VERIFICATION: At Hospitals • Non-cooperation by hospital owner in individual owned hospitals • No access in corporate hospitals • Delay in providing documents • The charges are not fixed and depend from patient to patient.

3. Hospital pharmacy does not share the computerized data and stock register. • Hospitalizations on weekends (in case of cashless cases) • Unaccounted expenses • Non-cooperation of certain agencies like school/ colleges, Employer – hence the delay.

4. Rude behavior by hospital owners/ consultants • Cannot control kick backs, excessive and unnecessary investigations

5. ROAD BLOCKS IN VERIFICATION: With insured • Refuse to give statements in writing • It is not possible to meet the unreasonable expectations of ICs which are also bad in law. • Neighbors do not provide statements.

6. ROAD BLOCKS IN VERIFICATION: With Physicians • Some doctors charge for giving statements. • They refuse to come face to face. • Non-availability of doctors • Rude behavior

7. ROAD BLOCKS IN VERIFICATION: With ICs • Authorization of patients not sent to verification agencies. • Policy T &C, Type of policy, details given by the patient in the proposal form is not made available. • Impracticable TATs.

8. ROAD BLOCKS IN VERIFICATION: Solutions • ICs should take cognizance of the grievances of verification agencies. • They should have a mechanism to take strict action against the defaulters. • The investigators should be given an authority and instructions to hospitals to honour their authority.

9. Pan India Presence • Criteria for selection of vendors. • Feasibility of PAN India agencies. • Assurance of volume. • Effectiveness of regional and zonal agencies vis a vis so called Pan India agencies

10. Ways to carry out investigations

11. INVESTIGATION ACTIVITIES • PRE INVESTIGATION • FIELD INVESTIGATION • POST INVESTIGATION

12. PRE INVESTIGATIONS • Peruse records thoroughly • Immediately note down the discrepancies • Prepare general plan of action for investigations • No place should be required to be visited twice- unless for follow up

13. PRE INVESTIGATIONS (Contd…) • Note down all contact numbers with names required for reference during field investigation • Note plan of action and visitation on single sheet • Plan of investigations • All points should be covered • Scope of investigations

14. PRE INVESTIGATIONS • Peruse claim documents and note details • Duration between policy and claim • Address • Age • Spacing of policies • Occupation/ license • Medical documentation • Habits • Hobbies etc.

15. FIELD INVESTIGATION • Before commencing, peruse the plan of action and plan of visitation • Make a visit to the place of occurrence • Take photographs • Do not take short cuts while investigating

16. FIELD INVESTIGATION (contd …) • Never ignore any additional information as unwanted • Get available verifiable documents and additional information verified for its authenticity. • In case of a lady name, get her maiden name. • Take all facts, statements in writing

17. FIELD INVESTIGATION (contd …) • Never leave work for next day. • Do not assume / deduce a fact or document to be true/ false on your own. Get it verified. • Do not automatically discredit information that is unfavorable to your position. • Do not assume non cooperation (Non- cooperation comes only where vested interests are involved.)

18. FIELD INVESTIGATION • Meet other doctors and chemists in neighboring areas of the treating doctor/ hospital. • Meet chemists near hospital, also pathology labs in the vicinity • If record not available with chemist near hospital, go to chemist near his residence • Also enquire with relatives, friends, colleagues, neighbors etc • Ask the nurse, peruse nursing notes • What was the cause? Do you have any knowledge about his cause of death ?

19. POST INVESTIGATION • Logical conclusion of investigation • Report to be in sequence of events • In simple language • Record multiple visits if done • Place all relevant evidence on record- including contact numbers.

20. POST INVESTIGATION (contd…) • Filing to be neat and proper • Send hard as well as soft copies • Index all contents in the report • If information to be obtained at a later date- mention so.

21. POST INVESTIGATION • Mention locality of the claimant’s residence. • Hospital- residence distance • Chemist- residence distance • Medical history details • Age proof • Occupation • Income and Source of income • Habits/ hobbies

22. POINTS TO BE KEPT IN MIND • Do your homework. • Documentation should be in detail • Always make check list for reference • Be polite but firm • Do not apply short cuts • Be thorough • Keep all necessary items required for investigations (tape, carbon paper, camera, pen etc.)

23. POINTS TO BE KEPT IN MIND • Bring evidence in support • Do not ignore additional information • First go to the opposite side where the insured lives • Ask open ended questions • Ask close ended questions only when we need to confirm facts • Remember to collect facts

24. Claimant’s Interview • Meet only if necessary • Meet him in the end • Be very polite but firm • Ask only relevant questions • Check for delay in date of death and intimation to the insurer. • Look for its reasons • Try to get more than 2 age proofs.

25. Age Proof • PAN Card/ Ration Card should not be collected as proof for age. • Instead voter’s list (preferably state list) can help. • How much should be the age difference for it to be significant: • If age is >60 years: Then upto 7 years • If age is <60 years: Then not more than 10 years

26. Never commit claim decision to the claimant to obtain documents • Take photographs of Life Assured and nominee • Take notice of living standard of nominee • Interview lady member in presence of some adult family member and record his/ her name. • Discretely interview children • Get details of his/ her mediclaim policies.

27. REMEMBER • Be thorough, polite, firm and alert • Collect all relevant documents • Do not leave any point unattended • Check the records and take the verification in writing • No need to obtain documents if already submitted to the company.

28. Details of family and dependents with age • Statement of spouse, colleagues, relatives, doctor etc. (preferably in their own handwriting) • Any other relevant details

29. TELE-CALLING • Hospitalization verification • Investigations before authorization • Investigations for PED in planned surgeries. • Investigations after claims are lodged. • Audit based investigations – getting triggers from audits (TPA oriented audits, hospital oriented audits)

30. PATIENT VERIFICATION AT THE TIME OF CASHLESS APPROVAL

31. Effectiveness of cashless verification. HOSPITALIZATION VERIFICATION STATISTICS DURING PERIOD 1-1-2011 TO 31-12-2011.

32. ROI

33. USE OF TECHNOLOGY • Permissions required. • CCTV permissions required for CCTV, Ham radio, walkie talkie- Ministry of telecommunication.

34. Sec 415 IPC • Whoever, by deceiving any person, fraudulently or dishonestly induces the person so deceived to deliver any property to any person, or to consent that any person shall retain any property, or intentionally induces the person so deceived to do or omit to do anything which he would not do omit if he were not so deceived, and which act or omission causes or is likely to cause damage or harm to that person in body, mind, reputation or property, is said to "cheat".

35. Explanation • A dishonest concealment of facts is deception within the meaning of this section.

36. Sec 463 IPC- Forgery • Whoever makes any false documents or false electronic record or part of a document or electronic record, with intent to cause damage or injury, to the public or to any person, or to support any claim or title, or to cause any person to part with property, or to enter into any express or implied contract, or with intent to commit fraud or that fraud may be committed, commitsforgery.

37. Sec 464 IPC- Making a false document • A person is said to make a false document or false electronic record who dishonestly or fraudulently  (a) makes, signs, seals or executes a document or part of a document;  (b) makes or transmits any electronic record or part of any electronic record;  (c) affixes any digital signature on any electronic record;  (d) makes any mark denoting the execution of a document or the authenticity of the digital signature,  • with the intention of causing it to be believed that such document or part of document, electronic record or digital signature was made, signed, sealed, executed, transmitted or affixed by or by the authority of a person by whom or by whose authority he knows that it was not made, signed, sealed, executed or affixed.

38. Sec 468 IPC- Forgery for purpose of cheating • Whoever commits forgery, intending that the document or Electronic Record forged shall be used for the purpose of cheating, shall be punished with imprisonment of either description for a term which may extend to seven years, and shall also be liable to fine.

39. Sec 471 IPC: Using as genuine a forged document or electronic record • Whoever fraudulently or dishonestly uses as genuine any document or electronic record which he knows or has reason to believe to be a forgeddocument or electronic record, shall be punished in the same manner as if he had forged such document or electronic record.

40. Sec 191 IPC: Giving false evidence • Whoever, being legally bound by an oath or by an express provision of law to state the truth, or being bound by law to make a declaration upon any subject, makes any statement which is false, and which he either knows or believes to be false or does not believe to be true, is said to give false evidence.

41. Explanation 1 •  A statement is within the meaning of this section, whether it is made verbally or otherwise. Explanation 2 •  A false statement as to the belief of the person attesting is within the meaning of this section, and a person may be guilty of giving false evidence by stating that he believes a thing which he does not believe, as well as by stating that he knows a thing which he does not know.

42. Sec 197 IPC: Issuing or signing false certificate • Whoever issues or signs any certificate required by law to be given or signed, or relating to any fact of which such certificate is by law admissible in evidence, knowing or believing that such certificate is false in any material point, shall be punished in the same manner as if he gave false evidence.

43. Sec 198 IPC: Using as true a certificate known to be false • Whoever corruptly uses or attempts to use any such certificate as a true certificate, knowing the same to be false in any material point, shall be punished in the same manner as if he gave false evidence.

44. Sec 199 IPC: False statement made in declaration which is by law receivable as evidence • Whoever, in any declaration made or subscribed by him, which declaration any Court of Justice, or any public servant or other person, is bound or authorized by law to receive as evidence of any fact, makes any statement which is false, and which he either knows or believes to be false or does not believe to be true, touching any point material to the object for which the declaration is made or used, shall be punished in the same manner as if he gave false evidence.

45. Sec 201 IPC: Causing disappearance of evidence of offence, or giving false information to screen offender • Whoever, knowing or having reason to believe that an offence has been committed, causes any evidence of the commission of that offence to disappear, with the intention of screening the offender from legal punishment, or with that intention gives any information respecting the offence which he knows or believes to be false: • If capital offence : 7 years • Punishable with life imprisonment : 3 years • punishable with less than ten years’ imprisonment : 1/4th part of the imprisonment

46. Sec 205 IPC: False personation for purpose of act or proceeding in suit or prosecution • Whoever falsely personates another, and in such assumed character makes any admission or statement, or confesses judgment, or causes any process to be issued or becomes bail or security, or does any other act in any suit or criminal prosecution, shall be punished with imprisonment of either description for a term which may extend to three years or with fine, or with both

47. Sec 17 Contracts act: Fraud • "Fraud" means and includes any of the following acts committed by a party to a contract, or with his connivance, or by his agents, with intent to deceive another party thereto his agent, or to induce him to enter into the contract; • (1) the suggestion as a fact, of that which is not true, by one who does not believe it to be true; • (2) the active concealment of a fact by one having knowledge or belief of the fact; • (3) a promise made without any intention of performing it; • (4) any other act fitted to deceive; • (5) any such act or omission as the law specially declares to be fraudulent.

48. Explanation.—Mere silence as to facts likely to affect the willingness of a person to enter into a contract is not fraud, unless the circumstances of the case are such that, regard being had to them, it is the duty of the person keeping silence to speak, or unless his silence, is, in itself, equivalent to speech.

49. TRAINING MODULE FOR INVESTIGATION- An Insight • Claim Investigation: Enquiry into unfamiliar and questionable issues

50. ATRIBUTES OF AN INVESTIGATOR • Inquisitive • Observant • Focused • Openminded • Curious • Perseverant • Persistent • Good Mannered