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The Middle East's Leading English Language Daily

Monday 24 November 2008 (27 Dhul Qa`dah 1429)

Fraud rampant in health care, say insurance experts
Sarah Abdullah | Arab News —

JEDDAH: As unfortunate as it is, fraud is becoming a problem in the health 
insurance sector. Those at fault, local insurance experts say, are usually the 
private sector health care facilities that resort to such activities to make a 
profit, leaving unsuspecting patients unaware that they have been ripped off.

According to statistics, health care fraud is one of the main challenges faced 
by the global insurance market today, amounting to a loss of at least 5 percent 
of all international premiums with between 6-15 percent of gross claims paid in 
various countries. Types of global fraud include doctor hopping, denial of 
pre-existing conditions, misapprehension of facts about illnesses and providers 
changing treatment descriptions.

The most common schemes found in Saudi Arabia, local insurance experts say, are 
unnecessarily large-scale orders for medical examinations, such as laboratory 
tests, MRIs, X-rays and CAT scans.

Another fraudulent scenario is “medication substitution.” Some private health 
facilities have been caught instructing doctors to prescribe expensive 
medicines and then allowing pharmacists to switch them with low-cost brands.

Acknowledging that fraud exists in the Saudi market, Mahmoud Awan, corporate 
marketing manager of BUPA Arabia, said, “The health insurance concept is 
relatively new to our society. There may be some people misusing it due to a 
lack of understanding of the process.”

He added that he expects time, information and experience to be involved in the 
preparation of properly utilizing the benefits of the health insurance system.

Raeed Al-Tamimi, vice president of Tawuniya, told Arab News: “Once a fraudulent 
act is discovered it will only lead to rejection of the claim and no 
compensation will be paid out.”

Speaking about measures that Saudi insurance companies follow to cut down on 
fraud, Al-Tamimi said: “Upon receiving requests for approval or bills from 
health care providers, our doctors carefully evaluate them. If there is any 
suspicion, an investigation will be carried out by our Fraud Review Unit.”

However, Awan said one of the first and most important things insurance 
companies can do in combating fraud is increasing social awareness and opening 
communication channels between insurance companies, patients and health care 
providers. “Fraud can be detected at various stages by verification of 
identity, following international guidelines and transparent communication 
between the concerned parties,” he said.

Awan said his company was exploring deployment of advanced technology, such as 
swipe cards and fingerprinting, with an aim to replace current verification and 
photocopying needs. “The move will considerably cut down waiting time at 
reception,” he said.

Al-Tamimi said Tawuniya has been able to detect numerous fraud attempts and 
terminate contracts with some local health care providers who were resorting to 
fraudulent billing practices.

He pointed out that work is being done to increase the ability of staff by 
conducting training courses in cooperation with Naif Arab University for 
Security Sciences in order to familiarize the personnel with the concepts of 
forgery, kinds of fraud, methods adopted for preservation of records, warranty 
signs and electronic data, vital standard measurements and combating 

He said Tawuniya had also begun implementing a rewards mechanism for reporting 
fraudulent claims.

Nonetheless, Al-Tamimi said with all of these safeguards in place to help 
combat fraud, the first line of defense in protecting the Saudi market and 
consumers should be good faith. He also said that insurance fraud is considered 
a criminal act globally.

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