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Undercover Patients to Unearth Health Insurance Malpractices
DUBAI — Decoy patients will be put into service to expose abuse and fraud in the network of insurance providers serving a scheme for Dubai government employees after a number of such cases emerged recently.
The ‘mystery shoppers’ will be deployed by the Dubai Health Authority at hospitals and clinics to investigate fraud cases discovered among the network of providers serving the Enaya insurance programme.
“This is a serious issue for us,” said Dr Haider Yousaf, Director of the Funding Department at the authority that decided to monitor the programme after the frauds were uncovered.
The authority found at least three cases in which healthcare providers (doctors) were falsifying patient’s symptoms and records so as to carry out expensive investigations that were not covered under the scheme. “Besides being unethical, this could prove dangerous for people,” said Dr Yousaf.
Enaya covers more than 80,000 beneficiaries in both public and private facilities. The network has over 100,000 service providers, said Dr Yousaf.
In one fraud case that was discovered, a physician tried to convince the patient that he should have a surgery, which is not covered under Enaya, to correct a refractive error. The physician falsified the patient’s symptoms and medical history, and fraudulently gave a false diagnosis allowing him to conduct expensive investigations despite knowing that the operation could not be approved.
The authority has taken strict note of the incident and the physician’s licence is under review, said Dr Yousaf. “Health insurance abuse and fraud is a common problem internationally, and our role is to keep strict supervision to prevent and minimise such occurrences.”
Besides deploying mystery shoppers, the authority will also assess change in behavioural patterns of doctors’ and carry out data monitoring to assess fraud.
Dr Yousaf said the department is taking a number of measures to minimise abuse and punish cases of fraud. “The first step is usually issuing a warning letter, but the authority has a range of punitive measures including removing the provider from the network, as well as taking legal action.”
He also said that attempts of fraud by beneficiaries can cause serious health risks to them in the long run. “Insurance culture is new in the country and we need to increase awareness among people,” said Dr Yousaf.
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