GPs and patients face court on health fraud charges

Doctors, patients and insurance providers accused of offences from fraudulent claims to using fake insurance cards

ABU DHABI // The Health Authority-Abu Dhabi (HAAD) is pressing charges against 39 patients, doctors and insurance companies for offences ranging from making fraudulent claims, to using fake insurance cards to charging for services that were never provided. The authority said it was taking the 39 offenders to court, and also intended to hit them with undisclosed fines.

Marwan al Naboulsi, the head of HAAD's enrolment and inspection department, said some doctors and insurance providers were padding their accounts by filing claims for medical procedures that were not performed. Some doctors were caught lying on claims for prescription drugs. They would prescribe patients drugs not covered by their provider, but write the names of covered drugs on the claims. Others pulled a similar switch with certain types of medical implants.

Some patients also tried to use forged insurance cards to receive free medical treatment, while some insurance providers were found to be shifting their insurance risk to other companies in violation of their trade licences. Mr al Naboulsi said the Government was trying to combat a growing amount of insurance fraud, which he said stemmed from the boom in the healthcare sector. He said that the authority planned to increase the number of inspections over the coming months. In 2009, it conducted 600 inspections.

Clinics and hospitals are often warned beforehand of inspections, but the authority also conducts some surprise ones. These are often based on tip-offs from patients or whistle-blowers. "We are in constant communication with health insurance scheme stakeholders to find means to reduce the risk of fraud," Mr al Naboulsi said. "Part of that is to protect and conceal the names of people who report violation of the law."

Daman, the country's largest health insurer, said in November that it had reclaimed Dh6 million in false claims, and would show fraudsters "zero tolerance". The insurer estimated that 1,500 fraudulent claims were filed each month, representing one per cent of claims. One health insurance expert, who asked not to be named, said the inspections were important as a method of curbing fraud, since "there's always going to be insurance fraud - if there is a system there is going to be a loophole to exploit."

Reducing fraud was essential because the cost to insurance companies would inevitably be passed on to consumers in the form of higher premiums, as the companies deal with the false claims, he said. However, a more immediate risk in cases such as stolen insurance cards is the alteration of a patient's medical history, which can lead, for instance, to prescribing medication that a patient is allergic to.

"Medically speaking, it's fatal," he said. "In a procedure, mixing up medical histories is never a joke." @Email:[e-mail]