The National Health Insurance Company (Daman) today announced the referral of a number of cases to the Criminal Court of Abu Dhabi on reasonable suspicion of fraud.

The legal action is part of a series of measures launched by the company in 2011 to curb medical insurance fraud and abuse, shielding its 2.1 million members from damages caused by professional misconduct on the part of healthcare providers.

The fraudulent cases that were referred to the Criminal Court includes violations pertaining to claims for unperformed and medical services, duplication of invoices, documents and prescription forgery as well as identity fraud.

Healthcare providers found to be committing fraud are immediately reported to the Health Authority – Abu Dhabi and later referred to the courts for further action.

“Fraud and abuse in medical insurance poses a risk to our members’ health and leads to financial losses, not just for the insurer but for the members in the form of inflated claims on their policies,” said Dr Michael Bitzer, Daman’s chief executive officer.

“Daman maintains zero tolerance for such violations and is taking every measure to limit the damage from fraud and abuse of health insurance.”

In 2011, Daman introduced a rigorous auditing protocol and prudent investigation procedures to support its medical auditors and investigators in detecting cases of potential fraud and abuse. The company also increased the number of professionals serving on its medical audit and investigation team to 25 professionals with medical backgrounds.

The team in 2011 investigated over 1,000 cases and audited over 500 medical service providers, including hospitals, clinics and pharmacies. The auditors routinely conduct a trend analysis of medical service providers for indication on potential cases of abuse or fraud. Daman also instituted a new fraud and abuse legal advisory team that works closely with government authorities on these cases.

“Medical investigation has been a priority for Daman from the time of its inception,” said Dr Jad Aoun, chief medical officer at Daman.

“We have planned a number of initiatives for 2012 to support this function, and are confident of further reducing instances of fraudulent claims and losses incurred from such professional misconduct.”

Added measures to reduce instances of fraud include a revised set of guidelines and bolstering the medical investigation and audit team with further resources. – TradeArabia News Service