If you read nothing else, read this…
- Insurers monitor the type of treatment that is standard in each country to ensure employees access treatment that is safe and appropriate.
- To help reduce fraud, insurers check every claim against their claims database and published price lists to ensure that the cost is reasonable and customary.
- If an insurer detects false charging by a provider, its investigations will not involve staff unless they have been affected or are party to it.
- Pre-authorising treatment enables insurers to reduce fraud by working closely with healthcare providers. It also provides reassurance about the treatment and provider.
If employees working overseas require healthcare treatment, their employers must take steps to guard against fraudulent charges and inappropriate medical procedures, explains Sam Barrett
Looking after the health of employees when they are posted abroad is important for many employers. But with staff accessing unknown healthcare facilities, there can be a risk of fraud or, worse of them receiving inappropriate and possibly dangerous treatment. Gerry Mould, international sales adviser at broker firm Medibroker, says: “Fraud is always an issue. We spoke to an insurer recently that had received a bill for five days’ in-patient stay for a broken arm. When it questioned the healthcare provider, it said this was a typing error.”
Lengthy stays for minor injuries, bills for courses of treatment that were never administered, and inflated charges are among the fraudulent practices insurers come across on international medical insurance policies.
The type of treatment an employee receives can affect the likelihood of fraud. With out-patient treatment, the employee pays the bill then claims it back from the insurer, so fraud is less of an issue. “As the patient knows what the treatment costs, they are more likely to question it if it seems unreasonable,” says Mould. “For in-patient treatment, where the employee does not normally see the bill, the risk of fraud is greater.”
The cost of bogus claims ultimately pushes up premiums for employers, so all insurers are keen to stress the steps they take to detect and stamp out fraud. Mark Coleman, director, international sales (UK) at Cigna International Expatriate Benefits, Europe, says: “Fraud is not common but we do take it very seriously. We want our customers to be sure they get value for money on their international medical insurance schemes.”
One of the main ways insurers can detect fraud is by checking charges against the pricing data they hold. Tim Slee, global sales director at Bupa International, says this data is used to help determine reasonable and customary charges for treatment in each country. “If a bill comes in that is higher than we would expect in that country, we will question it,” he says.
An insurer’s claims data can be augmented with information from other sources. For example, many countries produce a fee schedule to show what charges patients can expect. Also, insurers will often use local insurers and third-party administrators to get a better picture of a country’s charging structure. “We work with local insurers around the world,” says Coleman. “For instance, in Australia we partner with Grand United. This increases the data we hold, but also means we can use the connection to access better rates and relationships with the providers. This also helps to minimise fraud.”
Insurers can try to keep control of the cost of treatment by making direct billing arrangements with healthcare providers wherever possible. Coleman says about 95% of in-patient treatment is billed in this way, because providers often ask for a guarantee of payment before they will carry out treatment. Such an arrangement enables the insurer to question any unexpected costs much earlier in the settlement process.
Another important way to reduce the risk of fraud is by pre-authorising treatment. “We encourage policyholders to call us if they are having any treatment,” says Slee, adding that about 60% of claims are pre-authorised. “This allows us to speak to the healthcare provider and also gives the policyholder support. We can give them information and reassurance about the treatment and healthcare provider.”
If a fraudulent claim is unearthed, insurers stress it will not affect the employee involved unless they were party to it or had received potentially harmful treatment. Any treatment costs incurred by the employee would be reimbursed while the fraud investigation goes on behind the scenes.
As well as dealing with fraud, employers and insurers need to ensure that, wherever staff are in the world, they are not exposed to healthcare that could be harmful. Dr Sneh Khemka, medical director at Bupa International, says: “Medical procedures vary around the world. Something that is seen as experimental in one country may be the norm in another. Our team of clinicians monitors this, looking at the procedures that are carried out in different countries and ensuring they are appropriate and that our policyholders will be treated safely. Where this is the case, we are happy to pay for treatment.”