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Fraud and Abuse in Health Insurance Provider’s Perspective -Dr P. M Bhujang

Fraud and Abuse in Health Insurance Provider’s Perspective -Dr P. M Bhujang. Insurance. Two key words Contingency Trust. Fraud. Criminal Deception Dishonest Trick. Abuse. Improper use Unjust or corrupt practice. Consequences. Patient Hospital Doctors

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Fraud and Abuse in Health Insurance Provider’s Perspective -Dr P. M Bhujang

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  1. Fraud and Abuse in Health InsuranceProvider’s Perspective -Dr P. M Bhujang

  2. Insurance Two key words Contingency Trust

  3. Fraud Criminal Deception Dishonest Trick

  4. Abuse Improper use Unjust or corrupt practice

  5. Consequences Patient Hospital Doctors Insurance companies Health care costs

  6. RemediesInformation Clear and transparent Complete and comprehensive In the language understood by stake holders No hidden or in between the lines terms and conditions

  7. Information to all Stake holders • Concerned officials • Agents • Policy holders • Patients and Relatives • Doctors • Providers • Public

  8. Prevention Assistance in filling policy form Medical Examination Investigations Before and periodic at the cost of insurance company Assistance in filing claims

  9. Vigilance Monitoring Random checks Periodically interacting with providers Detecting deviations from norms in treatment and bills Audit Sharing information about defaulters

  10. Denial of payment • Blacklisting the policy holders • and providers • Informing the professional • bodies • Contd…. Deterrence

  11. Deterrence (Contd)… Taking civil and criminal action for breach of contract and cheating These must be intimated in the policy

  12. Responsibilities of the Insurance Companies and TPAs Transparency Service motto Equity Uniformity Confidentiality Contd….

  13. Responsibilities of the Insurance Companies and TPAs (Cond)… Promptness Pragmatic & flexible Policies Incentives for non-utilization Effective communication Willingness to pay penalty for unjustified delay or denial To face civil or criminal action in case of default

  14. Some common measures Laws for equitable justice Ombudsman Grievance committee consisting of all stake holders Use of media for right information

  15. Insure and be Secure is true…. but Ensure that Integrity is in full Measure

  16. Thank you

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