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Medical fraud is a harmful addiction

Clear guidelines on the use of medical insurance with specific definitions of insurance abuse will help to fight the menace, and keep overall costs down.

Making health insurance mandatory for all Abu Dhabi residents was an important step towards improving the health care system in the emirate. Now after eight years, more than 90 per cent of Emiratis and expatriates living in the capital benefit from that decision.

But as is the case with every health insurance system, benefits can be misused or abused. A recent government survey found that a third of the 450 people questioned reported being encouraged to get unnecessary tests by their doctors.

Among the 81 per cent who had medical insurance, 28 per cent said they had received inflated medical bills, which can result when doctors prescribe extra or unnecessary medicines or bill for undelivered or uncompleted services. About half reported knowing about fake medical certificates enabling people to have sick leaves.

No country in the world is immune to medical insurance fraud; large sums of money move through this sector of every economy, making accounting a challenge. But in the UAE, reports of fraud come amid skyrocketing outpatient medical costs, which the Government and private insurances have struggled to reign in. Daman, a national health insurance company that covers 80 per cent of Abu Dhabi's insured public, reports that since 2007 costs have climbed 26 per cent.

Run-away costs have many drivers, such as over-prescribing of medications and unnecessary visits. But fraud appears to be an out-sized part of this epidemic in spending. An estimated 30 per cent of all health insurance costs - Dh3.67 billion annual - are for payment of fraudulent claims or insurance abuse. Daman investigates more than 1,000 fraud cases a year; only a handful of doctors end up in court.

Closing this gap and wiping out fraud will take education, so consumers are able to identify and report misuse when it occurs, and don't abuse the insurance they have. Insurance companies should also consider sending patients clear billing details, so they see what procedures cost, and what was covered.

Ultimately, however, this challenge will require legal and legislative responses. Sven Rohte, chief commercial officer of Daman, notes that the federal health insurance law does not have a clear definition of medical insurance abuse. Until that changes, the epidemic of medical fraud and abuse will only continue.

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