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Head to head: Who’s responsible for detecting benefits fraud?

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Dave Patriarche:

Mark, I appreciate you taking the time to share this info. I agree with you on many of your comments but do come down harder on the insurers for a very simple reason. They alone, have the ability to inform employees of the consequences of fraud at the time of (or slightly before) claim.

Imagine a pop-up that said something like… “You are submitting a claim stating that you (or your dependent) have received this good/service outlined below, and paid the amount indicated. You also confirm you understand that you may be terminated from employment WITH CAUSE and prosecuted for fraud should the insurer find this service or payment had not been provided or paid for”

Another example would be a pop-up or e-mail (in the case of an EDI dental claim) that said something like… “if you did not pay the co-insurance portion of your dental claim, then you and your dentist have committed fraud and ….”

Technical solutions provided by insurers at time of claim would go along way to slowing the amount of fraud. Pop-ups or e-mails targeted to the specific item being claim and providing examples of fraud, would be even more successful.

The fraud is fraud video is a nice start, but the insurers should be held fully responsible as long as they have these tools at their disposal.

Wednesday, April 10 at 12:41 pm | Reply

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