x Abu Dhabi, UAEFriday 28 July 2017

Insurer says health care hit by fraud

Doctors commit fraud to have insurers pay for medication and procedures not covered by policies, providers say.

Daman says that the pain of insurance fraud will be felt by patients who are paying higher premiums.
Daman says that the pain of insurance fraud will be felt by patients who are paying higher premiums.

ABU DHABI // Doctors are committing fraud to have insurance companies pay for medication and procedures not covered by policies, insurers and health professionals say. The national health insurer, Daman, estimates that 1,500 fraudulent claims are filed each month, representing one per cent of claims. Such claims often involved falsifying details on a patient's chart to show that one treatment had been administered when in fact another, not covered by insurance, had been done. While sometimes patients may be aware of what the doctors are doing, often they have no idea that the treatment they need is not covered by insurance. "Unfortunately there are lots of fraudulent cases and it's been found that some doctors are writing something and practising something else," said Dr Jad Aoun, Daman's chief medical officer. Dr Aoun said falsified charts could create complications for patients, when doctors later relied on them for diagnosis. He said fraud cost insurers money and the losses were passed on to patients in higher premiums. "The moment my prices get inflated by the hospital, the same person who is paying the premium this year will pay more for his policy next year," Dr Aoun said. A Dubai-based doctor said part of the problem was with the insurers, as "health insurance companies should cover things that they do not cover". Another doctor, Dillan Shetty, an ear, nose and throat specialist from Al Amin Medical Centre, said: "Many doctors do it routinely to help people that are not covered." Dr Shetty, who said he did not commit fraud, claimed there were many cases of less altruistic fraud. "Misuse of insurance is rampant," he said. "There is an unhealthy collusion between the doctors and the patients which is going on. Patients will ask me to open a file in their name, but treat another person." Dr Shetty said many people in the medical community knew someone who defrauded an insurance company. He said people would ask for prescriptions which they would trade at pharmacies for shampoo or cosmetics. "There is one patient who said he got a prescription from a certain clinic and went to a specific shop with it to buy a watch," he said. "The watch company belonged to the owner of the pharmacy and there was an understanding." Some doctors in Abu Dhabi will prescribe contraceptive devices which are not covered under most health insurance plans, and write that they are performing routine check-ups. One doctor who claimed he does so said he thought it was unfair that the devices, which were commonly available in France, were not covered here. Daman has said that cosmetic surgery, which is not covered by most insurance plans, was often paid for through fraud. Insurance companies say such blatant violations are part of the reason they require stringent documentation from doctors. And they say there is little they can do about fraud unless patients complain. "The doctor is a trusted person," said Dr Mohammed Ezzat Agamy, the deputy chief medical officer and network director at Daman. "If you are a patient and you know your doctor is a cheater, do you accept him to treat you?" Insurers and doctors have been at odds over some aspects of the insurance process. As reported in The National, doctors have expressed concern that insurers are slow approving payments and interfere in clinical matters by refusing to approve funding for some treatments. amcmeans@thenational.ae