Tip-offs land Abu Dhabi health fraudsters in court

The Health Authority Abu Dhabi investigated ten healthcare providers, 45 insurance companies, six third party administrators and 179 medical professionals last year for fraudulent claims.

ABU DHABI // Hundreds of suspected fraudulent claims made by doctors and healthcare providers were investigated last year thanks to undercover investigations, tip-offs from patients and whistleblowers.

The Health Authority Abu Dhabi investigated 10 providers, 45 insurance companies, six third-party administrators and 179 medical professionals last year.

“We receive suspected fraud cases through whistleblowers, complainants, payers and providers,” said a spokeswoman for the emirate’s regulatory health organisation.

“There are always people trying to defraud any system.”

Fraudulent claims ranged from healthcare companies claiming for treatments and tests they had not given to a patient, falsely claiming for medical materials, and fraudulent use of health insurance cards.

Other cases included “misguiding the members”, or advising patients to undergo unnecessary tests or procedures to increase the claim the provider could submit to their insurance company.

The authority said an undisclosed number of offenders had been taken to court but could not reveal the amount it had reclaimed in false claims or estimate how much the fraudulent claims and insurance abuse could be costing the emirate each year.

“Any case not declared by court cannot be reclaimed. We direct the insurance company to recover from the violator after the decision is made by court,” the spokeswoman said. “Fraud cases are considered criminal offences. Therefore they should go through the judicial system.”

An important step in reining in unnecessary medical spending also lies in educating patients, the spokeswoman said. This includes spotting when their medical bills are unnecessarily inflated or when they are pushed to have additional tests or treatments that they might not have needed.

“Part of the health sector strategy is to control utilisation and to ensure that the care provided to the patient is medically appropriate, of good quality and cost effective, based on existing scientific evidence,” she said.

“Also, to raise the awareness on various issues related to health insurance with the aim of promoting rational use of the system.”

Haad has the power to suspend or revoke the licences of anyone found to be committing insurance fraud.

Dr Jad Aoun, chief medical officer at Daman, the country’s largest insurer, said exploitation of the health industry through fraud, misuse or waste, ultimately pushed up the cost of premiums.

“As a health insurer, entrusted with managing the premiums of our clients, we make great efforts to ensure that we address cases of fraud and abuse,” Dr Aoun said. “Our advanced IT systems and highly trained staff are able to detect probable cases of fraud and abuse for our investigators to review.

“While such cases are uncommon, we continue to improve our detection methodologies.”

In 2013, a report by consultancy group Booz Allen Hamilton estimated that the UAE was losing more than Dh3.67 billion a year on health insurance abuse or fraud.

Abu Dhabi became the first emirate to introduce compulsory health insurance in 2006, requiring all workers and dependants be given health insurance by their sponsor. There is a separate comprehensive insurance programme for Emiratis.

By 2012, 98 per cent of residents in Abu Dhabi were covered by insurance.