WORKSHOPCONTROLLING FRAUD AND ABUSE IN

HEALTH INSURANCE

COLLEGE OF INSURANCE (INSURANCE INSTITUTE OF INDIA)

23-24 February 2012

Setting the Context

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05/07/23 2

CONTROLLING FRAUD & ABUSE IN HEALTH INSURANCE

College of Insurance (III) Workshop on Fraud and Abuse in Health Insurance

05/07/23 3May 7, 2023College of Insurance (III) Workshop on Fraud and Abuse in Health Insurance

CONTROLLING FRAUD & ABUSE IN HEALTH INSURANCE

05/07/23 4May 7, 2023

III

Society where insurance fraud is acceptable.

Business focus has changed:From Property to Personal linesFrom Corporate to RetailFrom Large Amounts to Large Numbers

To a different business model – no cross subsidyTo a different type of Risk & its ManagementHuman Beings whose behavior cannot be readEnvironment of changed life-style, disregard for rules, no plans for loss prevention, ignorance of insurance.Health service providers – enough regulated ??Intermediary’s role – enough supervised ??Reduced sympathy from Judiciary/ Media.College of Insurance (III) Workshop on Fraud and Abuse in Health Insurance

CONTROLLING FRAUD & ABUSE IN HEALTH INSURANCE

5

WORKSHOP CONTROLLING FRAUD AND ABUSE IN

HEALTH INSURANCE

COLLEGE OF INSURANCE (INSURANCE INSTITUTE OF INDIA)

23-24 February 2012

Workshop Agenda

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We do knowWe do know How Fraud happensHow Fraud happens

- by providers, - by providers, - by customers, - by customers,

- by sales/agency force- by sales/agency force How How

- to set triggers, how to analyze data- to set triggers, how to analyze data- to develop processes, IT systems to do above- to develop processes, IT systems to do above- to investigate, how to ‘catch’ fraud- to investigate, how to ‘catch’ fraud

Do we know..Do we know..• The results of our efforts…whether fraudThe results of our efforts…whether fraud

- is growing?- is growing?- has reduced?- has reduced?

Whats the exact quantum, numbers…is it worth the Whats the exact quantum, numbers…is it worth the effort..the worry..the work…effort..the worry..the work…

Is it only numbers or concern of polluted eco Is it only numbers or concern of polluted eco system, system,

customer’s health and money, the drain on customer’s health and money, the drain on resources resources

What recourse world has adopted to deal with What recourse world has adopted to deal with sophistication of fraudsterssophistication of fraudsters Are we geared, equipped, prepared.. Are we geared, equipped, prepared..

The WorkshopThe Workshop Basic Premise – learn togetherBasic Premise – learn together Compete vs co-operateCompete vs co-operate Ready to share – best practices, information, dataReady to share – best practices, information, data Work together for industry level initiative, anti-fraud Work together for industry level initiative, anti-fraud

forum, better and stringent laws, punitive actionforum, better and stringent laws, punitive action Specific Outcomes –Specific Outcomes –

- Define fraud and abuse, role & responsibility of - Define fraud and abuse, role & responsibility of each player each player- Best practices for preventing/detecting fraud- Best practices for preventing/detecting fraud

- Dealing with fraud in mass schemes- Dealing with fraud in mass schemes

Workshop Format Workshop Format Group brain storming and presentations -Group brain storming and presentations - 4 groups covering entire spectrum 4 groups covering entire spectrum 4 Panel discussion sessions4 Panel discussion sessions - International Practices- International Practices - Provider perspective- Provider perspective - Investigating Agencies perspective- Investigating Agencies perspective - IT Interventions and solutions- IT Interventions and solutions Concluding Panel discussion – Way ForwardConcluding Panel discussion – Way Forward

07/05/23College of Insurance (III) Brokers'

Session 10

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