THE BLOG

Fraud Health Claims Costing Facilities To Genuine Patients

26/11/2014 10:28 GMT | Updated 25/01/2015 10:59 GMT

The warning bells have been ringing since quite a while now. And, if authorities are able to check this before it gets beyond control, it would make a world of difference to those genuine patients who are having trouble getting their claims processed. Owing to a few bad eggs in the basket who claimed false health insurances to fund their holidays or something fancier, a lot of deserving patients have been put through hardship of delayed claim settlement.

The problem is not restricted to one country. But, in the recent times, National Health Service - the public funded healthcare system in UK is on the verge of facing some difficult times, thanks to fraud claims that have been costing quite a bit of taxpayers' money. Because NHS is primarily funded through general taxation system which provides healthcare to every legal resident of UK with most services being made available free.

However, the concern about continuing these services for genuine cases has turned into a challenge. Because the size of fraud claims in UK today is simply beyond wildest of imagination. Surveys in the recent past have revealed the amount of misuse and the numbers are beyond staggering.

Every day, UK has at least 324 fake insurance claims that come in for further processing, as per the annual data that was available last year. The data that is available with the Association of British Insurers (ABI) reveals that insurers detected 118,500 fraudulent or fudged insurance claims in 2013.

The average value of such fake claims stood at £ 10,813! According to the ABI, the value of 'dishonest' claims has been on the rise since 2007 with the numbers increasing by a good 30% every year.

This led to establishing of Insurance Fraud Enforcement Department a specialist unit that was established in 2011. So far, this organisation has arrested 470 persons and has prosecuted 85 of them for insurance frauds.

Actually, quantifying the healthcare fraud is a desirable thing, and yet the most complicated thing to do as well. It is problematic at its best. Because, the data available for such investigations would be somewhat unclear right at the very outset; but what happens to those claims that are well-organised in terms of being fudged?

In any case, deriving conclusions based on the available data suggest that NHS has been losing nearly £ 3.35 bn every year on patient care, thus resulting in denial of health care for those who actually need to come under its cover. Because, the amount of fraud within NHS is substantial, and enough to affect the services extended to others by way of curtailing the access.

Though prosecuting false claims out serious message to fraudsters, more tangible steps have to be taken to ensure the claims simply don't land on the desk of those processing agencies, hoping never to be found out. This problem, in other words, needs to be nipped in the bud before 'chance' takes over the minds.

A 72-year-old Isabel Parker gained over $ 500,000 claiming she slipped and fell at various locations - including liquor stores and various properties. She would file a case and when the companies approached her for out-of-court settlement, she would accept and end the matter. Her game came to an end in April 2004 when her claims were found to be false and she was sentenced to 29 months of jail term.

John Darwin faked his death while being in a canoe out on an adventure trip to end his loan worries. His wife was part of the game and everyone seemed to be convinced, including their adult sons and the police. When he and his wife used the money to buy a property elsewhere in UK, their game was deemed over.

Such cases are aplenty with even more gory details with people going to any length to use the fake claim to their advantage.

Having woken up to this problem long time ago, the US has been dealing with this issue in much more efficient manner, US healthcare system provides some tangible pointers to deal with fraud cases and reduce their numbers.

However, estimating the quantity of healthcare fraud in US is as difficult owing to the size of population and the intrinsic difficulty of detecting it is a tough job. Private healthcare providers overcharge insurers including the federal Medicaid and Medicare programmes, making patients condition more severe than it actually is, on papers. To mitigate the issue, USA has introduced False Claims Act which would give financial incentives to whistleblowers thus making investigation a proactive one.

Todd Spodek, a medicaid fraud lawyer in New York City states that those in the US who take brisk action early on in a fraud investigation can often avoid criminal prosecution.

Perhaps taking a leaf out of this, NHS could come up with more stringent clauses for claiming the health insurance, ensuring the money and facilities are used by those who truly deserve it.