Abu Dhabi: The misuse of health insurance coverage, including over-prescription for medicines and unnecessary tests, are pushing up the costs of insurance premiums in the UAE by nearly 20 per cent, the Ministry of Interior revealed in a recent report.
The report also added that such misuse, as well as instances of insurance fraud, were leading to fewer benefits and higher payment shares for the insured.
About 450 residents were surveyed for the purposes of the report, and nearly 28 per cent of them said they had been advised to undergo unnecessary tests that inflated the medical bill. More than 50 per cent of respondents also said they knew of people who filed for false sick leave, while another 49 per cent said they knew of at least one person who had used fake medical certificates.
The ministry’s report, which was published in the its monthly 999 publication, also cited studies made by insurance companies in 2011 which claim that misuse accounts for nearly 30 per cent of health insurance spending.
Since 2008, employers in Abu Dhabi have been mandated to provide insurance coverage for all workers. However, the Health Authority Abu Dhabi (HAAD) that oversees insurance companies in the emirate received 900 insurance-related complaints in 2011 alone, of which at least six were referred to the courts.
One of the most common examples of fraud is upcoding, where a medical provider bills the insurance provider for a similar but more expensive patient procedure to maximise payout. As Gulf News reported last year, other types of misuse include unnecessary cosmetic procedures, unperformed medical services (such as sick leave) and filing the same insurance claim twice.
Dr Hazem Al Madi, chief executive officer of Green Crescent Insurance Company and head of the life and medical committee at the Emirates Insurance Association, told Gulf News that the company saw only about five per cent of insurance misuse pertaining to unperformed services, including surgeries and sick leave.
“Nearly 20 per cent of the cases refer to unnecessary tests, duplicate claims and over-utilisation of the insurance coverage,” he said.
The National Health Insurance Company (Daman), which provides coverage for 2.1 million members at present, also announced that it audited 500 medical service providers last year and investigated over 1,000 claims.
Dr Sven Rohte, chief commercial officer at Daman, also stressed that an increase in the rate of health insurance abuse and misuse places pressure on employers to cut back on benefits.
“We have noticed that acts of insurance misuse or fraud are not yet perceived as a crime. For example, individuals often ask pharmacists to exchange drugs listed on the prescription for diapers, and bill the insurance company for the cost,” Dr Rohte said.
Dr Al Madi recommended that the community act together to prevent a situation where the inflation of insurance premiums continues.
“Residents must report any suspected cases of abuse, as they ultimately suffer from fewer benefits when insurance inflation occurs, or increases in payment shares. Regulatory authorities must also take action so that medical providers do not set targets for their staff, which then pushes some professionals to push for unnecessary treatments. Insurance companies must implement their own methods of detecting fraud,” he said.
