health insurance fraud in Saudi Arabia
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Chandigarh University *
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Course
152
Subject
Health Science
Date
Nov 24, 2024
Type
pptx
Pages
17
Uploaded by rcbati89
HEALTH INSURANCE FRAUD IN SAUDI ARABIA
Presenter name
INTRODUCTION
•
Health insurance fraud is a growing problem globally, and Saudi Arabia is not an exception. •
The purpose of this presentation is to educate employees on the issue of health insurance fraud and to show them how they can act appropriately when processing health insurance claims.
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WHAT IS HEALTH INSURANCE FRAUD?
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Health insurance fraud is the act of intentionally deceiving or misleading a healthcare provider or insurer to obtain payment for services not covered by insurance or to receive payment for services not rendered (Villegas-Ortega et al., 2021). •
It affects the healthcare system in Saudi Arabia by increasing the cost of healthcare and decreasing trust in the system. 3
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ACTIONS THAT WOULD BE CONSIDERED FRAUDULENT
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The following actions would be considered fraudulent in the healthcare industry:
falsifying medical records
billing for services not performed
upcoding (i.e. billing for a higher level of service than was actually provided).
WARNING SIGNS OF FRAUD
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The following are some key indicators that fraud may be present in a healthcare organization:
A high volume of claims for a specific treatment or procedure
Claims submitted for services not covered by insurance
Claims submitted under a false name or Social Security number
IMPACT OF FRAUD
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1. The Effect on Healthcare Providers
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Health insurance fraud impacts the medical community by increasing costs for healthcare providers and decreasing trust in the healthcare system (RightPatient, 2020).
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CONT…
2. Impact of Fraud on Health Insurance Companies 7
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Health insurance fraud affects health insurance companies by increasing costs for the company and decreasing trust in the company by its customers (Jain & Sten,
CONT…
3. Impact of Fraud on Patients
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•
Health insurance fraud can have serious impacts on patients like:
1. Increased healthcare costs
2. Reduced access to care
3. Denied claims
4. Loss of personal information
5. Damage to reputation
CONT…
4. Impact of Fraud on Saudi Arabia
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•
Health insurance fraud impacts the entire nation of Saudi Arabia by increasing healthcare costs, decreasing trust in the healthcare system, and putting a strain on the nation's economy.
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REPORTING FRAUD
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To report health insurance fraud in Saudi Arabia, individuals should contact the Ministry of Health or the National Anti-Fraud Task Force and provide information such as the name of the person committing the fraud and any evidence supporting the claim (Sowah et al., 2019).
CONSEQUENCES FOR FRAUDULENT BEHAVIOR
The penalties for those who participate in health insurance fraud in Saudi Arabia include:
1.
Fines 2.
Termination of Job contract
3.
Imprisonment. 11
PREVENTION OF FRAUD
To prevent health insurance fraud in Saudi Arabia, healthcare organizations can:
1.
Implement procedures for screening claims 2.
Provide training for employees on how to identify and report potentially fraudulent activities. 3.
Impose in-house liability to fraudulent activities
12
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1. IMPLEMENTING PROCEDURES FOR SCREENING CLAIMS:
Healthcare organizations can establish systematic procedures for screening claims
Screening claims can help detect and prevent fraudulent activities, and reduce the costs associated with such activities (Healthcare Risk Group, 2019).
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2. PROVIDE TRAINING FOR EMPLOYEES
By providing training on how to identify and report fraudulent activities, healthcare organizations can ensure that employees are equipped with the knowledge and skills necessary to detect and prevent fraud (Alonazi, 2020).
This could include training on recognizing red flags such as unusual billing patterns, suspicious claims submissions, or requests for services that are not medically necessary.
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3. IMPOSE IN-HOUSE LIABILITY TO FRAUDULENT ACTIVITIES
Healthcare organizations can take steps to hold employees accountable for fraudulent activities committed within the workplace.
This could include implementing policies and procedures that clearly outline the consequences of engaging in fraudulent activities and imposing disciplinary measures, such as termination of employment, for employees who are found to have committed fraud (Puteh et al., 2020).
This can help to deter employees from engaging in fraudulent activities and can send a clear message that such behavior will not be tolerated.
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CONCLUSION •
Health insurance fraud is the act of intentionally deceiving or misleading a healthcare provider or insurer to obtain payment for services not covered by insurance or to receive payment for services not rendered (Villegas-Ortega et al., 2021). •
It impacts the entire nation of Saudi Arabia by increasing healthcare costs, decreasing trust in the healthcare system, and putting a strain on the nation's economy. •
To prevent health insurance fraud in Saudi Arabia, healthcare organizations can:
1.
Implement procedures for screening claims 2.
Provide training for employees on how to identify and report potentially fraudulent activities. 3.
Impose in-house liability to fraudulent activities
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REFERENCES •
Alonazi, W. B. (2020). Fraud and abuse in the Saudi healthcare system: a triangulation analysis. INQUIRY: The Journal of Health Care Organization, Provision, and Financing, 57, 0046958020954624.
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Healthcare Risk Group. (2019). Healthcare Fraud and its Consequences. [HRGPros.com]. https://www.hrgpros.com/blog/healthcare-fraud-and-its-consequences
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Jain, A., & Sten, R. (2020). Healthcare Fraud: A Systematic Review of Literature. Journal of Medical Systems, 44(10), 496. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7522845/
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Puteh, S. E. W., Aizuddin, A. N., & Al Salem, A. A. (2020). Renewal of Healthcare Funding Systems by National Health Insurance in the Kingdom of Saudi Arabia (NHI).
•
RightPatient. (2020). Health Insurance Fraud Impact on Healthcare Systems. [Rightpatient.com]. https://www.rightpatient.com/guest-blog-posts/health-insurance-fraud-impact-on-healthcar
e-systems/#:~:text=Cases%20like%20these%20affect%20our,expenses%20and%20rising%20insuran
ce%20premiums
. •
Saldamli, G., Reddy, V., Bojja, K. S., Gururaja, M. K., Doddaveerappa, Y., & Tawalbeh, L. (2020, April). Health care insurance fraud detection using blockchain. In 2020 Seventh international conference on software defined systems (SDS) (pp. 145-152). IEEE.
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Sowah, R. A., Kuuboore, M., Ofoli, A., Kwofie, S., Asiedu, L., Koumadi, K. M., & Apeadu, K. O. (2019). Decision support system (DSS) for fraud detection in health insurance claims using genetic support vector machines (GSVMs). Journal of Engineering, 2019.
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Villegas-Ortega, J., Bellido-Boza, L., & Mauricio, D. (2021). Fourteen years of manifestations and factors of health insurance fraud, 2006–2020: a scoping review. Health & justice, 9, 1-23.
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