WORKSHOP
CONTROLLING FRAUD AND ABUSE IN
HEALTH INSURANCE
COLLEGE OF INSURANCE
(INSURANCE INSTITUTE OF INDIA)
23-24 February 2012
Setting the Context
1
CONTROLLING FRAUD & ABUSE IN HEALTH INSURANCE
7/29/2017
College of Insurance (III) Workshop on Fraud and Abuse in Health Insurance
2
CONTROLLING FRAUD & ABUSE IN HEALTH INSURANCE
7/29/2017
29-Jul-17
College of Insurance (III) Workshop on Fraud and Abuse in Health Insurance
3
CONTROLLING FRAUD & ABUSE IN HEALTH INSURANCE
Business focus has changed:
From Property to Personal lines
From Corporate to Retail
From Large Amounts to Large Numbers
III
To a different business model – no cross subsidy
To a different type of Risk & its Management
Human Beings whose behavior cannot be read
Environment 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.
Society where insurance fraud is acceptable.
7/29/2017
29-Jul-17
College of Insurance (III) Workshop on Fraud and Abuse in Health Insurance
4
5
WORKSHOP
CONTROLLING FRAUD AND ABUSE IN
HEALTH INSURANCE
COLLEGE OF INSURANCE
(INSURANCE INSTITUTE OF INDIA)
23-24 February 2012
Workshop Agenda
6
We do know


How Fraud happens
- by providers,
- by customers,
- by sales/agency force
How
- to set triggers, how to analyze data
- to develop processes, IT systems to do above
- to investigate, how to ‘catch’ fraud
Do we know..
•




The results of our efforts…whether fraud
- is growing?
- has reduced?
Whats the exact quantum, numbers…is it worth the
effort..the worry..the work…
Is it only numbers or concern of polluted eco system,
customer’s health and money, the drain on resources
What recourse world has adopted to deal with
sophistication of fraudsters
Are we geared, equipped, prepared..
The Workshop





Basic Premise – learn together
Compete vs co-operate
Ready to share – best practices, information, data
Work together for industry level initiative, anti-fraud
forum, better and stringent laws, punitive action
Specific Outcomes –
- Define fraud and abuse, role & responsibility of
each player
- Best practices for preventing/detecting fraud
- Dealing with fraud in mass schemes
Workshop Format



Group brain storming and presentations 4 groups covering entire spectrum
4 Panel discussion sessions
- International Practices
- Provider perspective
- Investigating Agencies perspective
- IT Interventions and solutions
Concluding Panel discussion – Way
Forward
29/07/2017
College of Insurance (III) Brokers'
Session
10
11