Undercover patients to unearth insurance abuse

BY PMA RASHEED

The Gulf Today, 1 April 2010

Cases of fraud and abuse of Enaya health insurance programme among hospitals and clinics of Dubai will be investigated by a team of undercover patients appointed by the Dubai Health Authority (DHA).

The undercover patients named "mystery shoppers" dispatched by the DHA’s Health Funding Section will detect the insurance abusing cases, in the wake of recent increase in such fraudulent incidents among the network of providers serving the Enaya insurance programme, according to a senior health official.

The Enaya is a health insurance programme for employees of the Government of Dubai.

Considered as the most comprehensive health insurance package available in the emirate, the Enaya promotes the health and safety of its employees and their families, incorporating a large component of screening and preventive benefits to them.

The Enaya insurance programme covers more than 80,000 beneficiaries representing the government employees and their families, where they receive health services of the highest quality in both public and private facilities as well as outside Dubai.

Dr Haidar Al Yousuf, Director of the Funding Department at DHA, pointed out that the initiative to monitor the programme for exposing the fraudulence is aimed at protecting the rights of Enaya health insurance beneficiaries and ensuring that they receive the highest quality of services.

“The health funding section recently uncovered a number of fraud cases. In a case, a physician tried to convince the ‘mystery shopper’ enacted as patient to undergo a surgery to correct a refractive error,” he said.

“The physician falsified the patient’s symptoms and medical history, and fraudulently gave a false diagnosis in order to perform the surgery, which was not covered under the Enaya. The physician conducted expensive investigations, which in this case are only needed as a prerequisite for the operation, despite knowing that the operation could not be approved by Enaya,” explained Dr Al Yousuf.

According to him, the DHA’s efforts are to impose stringent penal actions to prevent and minimise the occurrence of health insurance abuse or fraud that has emerged as a global issue.

“The implementation of the 'mystery shoppers' is considered to be an effective tool to trap the frauds, as part of the DHA’s current plans to minimise the abuse cases,’ he added.

“The first step of punitive actions will be issuance of a warning letter, but the DHA has a range of punitive measures including removing the provider from the Enaya network, as well as taking further legal actions,” pointed out Dr Al Yousuf.

“However, controlling the cases of insurance abuse of fraud will not be achieved unless we receive full cooperation of all interested parties, particularly the Enaya beneficiaries,” he noted.

He said that vigilance of the beneficiaries by being proactive can contribute to prevent the fraudulent activities by service providers such as ordering unnecessary investigations or sending claims for services that were never provided.

Dr Al Yousuf also added that attempts of fraud by beneficiaries can cause serious health risks to them in the long run.

“For example, he explained, pretending to need certain medicines and then giving those medications to a relative, caries serious risk. While there are ethical and legal responsibilities, these actions could have enormous health risks to the beneficiary, since physicians depend on the information in the medical record to reach a correct diagnosis and give the right treatment,”

“Having false medical information may cause the healthcare provider to reach a wrong or an inaccurate diagnosis, or give wrong treatment which is particularly dangerous in cases of emergency,” said Dr Al Yousuf.