Fraud in Private Medical Insurance

Fraud is a small but important problem within the medical insurance industry. Customer fraud is negligable as the providers are very tight in their proceedures and generally payments are made direct to those that give medical care.

However another form of industry deceptionis provider fraud, the most common types of which are upcoding, misrepresentation of the treatment provided or the patient’s medical history, charges for procedures not actually performed and unbundling. However one of the main problems with tackling fraud within the private medical insurance business is that it is difficult to spot.

Recently the General Medical Council suspended Dr Ahluwalia from practising this year for upcoding claims to the value of £85,000. This consultant billed 100% of procedures as being for therapeutic gastroscopy whereas infact four health insurance companies gave evidence to a hearing to the effect that while the stomach had been examined, no actual treatment had been given. What is most disturbing to me about this case and others is that the fraud has the potentional to impact so greatly on the consumer. Our premiums have to be raised to cover this waste of revenue!

The Health Insurance Counter Fraud Group UK (HICFG) is an industry initiative to prevent and detect fraud within healthcare and the insurance industry. The HICFG have 11 member health insurance companies, including Cigna, Pru Health and Standard Life Healthcare.