1. Methods/ Best Practices Fraud prevention and detection Group 2
Insurance Institute of India, Mumbai
24th February 2012

2. Interplay between Policy and Care
More defined Terms and Conditions of Insurance Policy: ailment exclusions/ wait period, procedure caps, waiting period, deductibles
Rising sensitivities to:
care delivered and rate plans followed by providers
Variations between planned care and delivered care
Episodic transaction during loss incidence i.e. hospitlisation

3. Active Participation…..

4. Factors in fraud management Leaks, Misrepresentation, Inflation, Fabricated cases
Detectability:
Wrong information, pattern, trend, adverse event
Severity: Loss amount
Frequency: number of cases
Remedial action
Impact of remedial action

5. Detectibility Welcome call before issuing policy.
Risk Scoring against weighted criteria (Tolerence levels and concurrent audit)
Organised data (template) to prompt detection of gaps/ deviation from routine
Std Treatment Guidelines (Routine elements of diagnosis, care and prognosis):
Train claims assessors to detect non routine elements and confirm rationale with provider
Medical Audits, Infrastructure Audit of Providers
Triggers: Age, Gender, ICD group, lockin period, Locn (provider; Locn (member); Cashless/MR; Claimed amt;
Investigators:
Training Modules to build competency
Establish and communicate Code of Conduct for investigation function
Data Sharing:
ICD 10 coding
Common shared folder between common interest groups
Trends and Patterns: Agent, Cashless, MR

6. Severity
Tele Follow Ups for suspicious cases on events during care process.
Case Management for high value claim or catastrophic treatment (eg Multiple injuries)
Second opinion by qualified doctor in similar speciality preferably in same region
Checklist to insured member to track hospitalisation events for planned care (eg Diagnostic tests, Decision of admission, informed consent, preauth request, approval terms and conditions, assessment, care, prognosis, discharge)

7. Frequency
Shared Data and Joint assessment of experiences against trends and patterns
Red alerting suspicious providers vis-à-vis ICD groups and black listing fraudulant providers
Shared knowledge on status of suspicious hospitals across TPAs, Ins Companies
Learnings (Improving) and Unlearnings (simplifying)

8. Corrective Actions Remedial action (control):
isolate cause/ environment of cause: Deny cashless while hospitalisation; suspend cashless facility to provider pending investigations.
reduce loss: mediation, negotiation, arbitration (sensitivities with legal action)
Recover loss: To establish mechanism and process of recovery post- retrospection
Impact of remedial action:
Amount recovered
Leak stopped (potential loss avoided)
Sustenance of control measures (detection, compliance, deterministic)

9. Preventive Measures Sustenance of effective actions
Committee for knowledge creation from current experiences, patterns and trends.
Committee to approve best practices and propagation
CME for Medical staff in Insurance segment
Newsletters for member groups
Newsletters for provider groups
Thoughts!
Automation of consistent processes
Algorithm (statistical) based decision prompt

10. Possible methods
Assess care Vis-à-vis hospital infrastructure and specialties included (A scale to measure hospital compliance available) especially for Non NW Hospital with high volume of cases and/ or high claim value.
Insurance specific ‘Informed consent’ to capture member behaviour Vs provider behavior
Credentialing and performance tracking of investigators
Regional committees to resolve disputes between parties and close the open cases.
Change in accreditation status with NABH, Licencing authority may benefit by avoiding potential fraud
Published fraud hospital list has legal implications and not suggested
Reporting to Police, MCI, Statutory Licencing authority, IMA has not yielded positive responses

11. Thank You