Supplier fraud and abusive practices

Senior Vice-President and Chief Administrative Officer of AIG Travel, James Page, opened the first ITIC session of the week with a focused presentation on fraud and abusive practices in Latin America.

As people travel more, quality of care tends to improve in the regions being visited. But this uptick in travel also equates to a growing threat of fraud. In Latin America specifically, James explained that providers tend to see higher service costs and over-billing. And this is especially true in popular tourist destinations. The most common abusive practices include unnecessary procedures such as hospital admissions and tests, fabricated cases, unnecessary surgeries, and being billed for surgeries that weren’t even performed in the first place. Elsewhere, James noted that some places take a ‘shot-gun approach’ to billing; requesting payment to different centres instead of sending bills to the appropriate department, which in some instances can cause duplicate payments.

He used the example of a billing incident in Columbia in which a patient needed urgent appendicitis surgery. “If you’re not familiar with the surgery, look it up,” he advised. Often fraudulent companies take a very creative approach. “When the money goes out, you’re not getting it back,” James assured and, as such, having the right indicators in place is key to ensuring that insurance and assistance companies are able to identify and deter potential fraudulent cases.

With the discussion opened up to the room, the session attendees covered the importance of screening processes to detect ransomware attached in email correspondence, as well as touching upon the annual percentage lost through fraudulent activity (for AIG Travel, this equated to around 0.9 per cent, with roughly four to five per cent of the claims the company received being identified as fraudulent each year). James also noted that training on fraud was another important method to deter fraud – “People understand that we’re paying attention, and this helps keep the numbers down,” he said.

Carol Foley, Co-Founder of Fairmount International, headed up the second part of the session, focusing on fraud in Sub-Saharan Africa. She noted that while the quality of care in Africa is improving, there are still discrepancies among the different countries in the region. She said that, in 2016, the World Health Organization cited the global healthcare spend as US$7.5 trillion. And between 2008 and 2013, the Center for Counter Fraud Studies noted that the estimated percentage of fraud was at 6.19 per cent; an increase compared with previous years.

Carol explained that in Sub-Saharan Africa, fraud consists of billing for services not rendered; the misrepresentation of key claims information (including dates, locations and type of provider); over treatment; and false or unnecessary prescription of medicine. “The players are shrewd, and people need to keep alert to that kind of activity,” she warned.

Carol referenced two case studies, one of which detailed an instance of fraud in Cameroon in which a claim for a 42-year-old male who was diagnosed with malaria came in on a hand-written invoice. The drugs prescribed for the case were potentially toxic and could have proved fatal to the patient. Upon a visiting analysis from Fairmount International, the team discovered that the doctor who allegedly wrote the report was long deceased. The claim was ultimately denied as the case itself turned out to be entirely fabricated, and the patient didn’t exist.

A take-away point is that collaboration is extremely valuable in the fight against fraud and abusive practices, as is AI. “Medical providers, insurers and assistance partners all need to work together to minimise fraud,” Carol highlighted.

Rounding up the first session of the week, Dr Sundeep Dhillon, Chief Medical Officer at MAPFRE, began his presentation with an immersive clip on medical assistance on Mount Everest, with a view to discussing helicopter fraud in Nepal. His presentation covered altitude sickness, which he reasoned can be difficult to distinguish from the general experience of everyone else engaging in mountaineering activities.

Dr Dhillon explained that in Nepal 20 years ago, most of the treks were sold pre-trip by Western companies, whereas, more recently, a massive ‘explosion’ of trekking companies has resulted in local businessmen ‘over-promising’ and ‘under-delivering’ on the Everest experience. In some cases, travellers are being offered helicopter evacuations in advance of their trip, as well as luxury accommodation after transportation. And it’s not just the air rescue companies committing fraud; trekkers and guides are also committing fraud and, as a result, insurers are blindsided due to a lack of communication. What’s more, Dr Dhillon argued that because cases are time-sensitive, insurers rushing to act quickly – due to short weather windows and air ambulances’ inability to fly at night – can further hinder the process of authenticating a claim.

Dr Dhillon referenced specific types of fraud, including multiple rescues in the same helicopter, where claimants received a bill for the cost of the whole helicopter, rather than splitting the bill.

Unless you have a presence in Kathmandu and know people, you are not taken seriously, he said. And, as such, Dr Dhillon explained that he has taken great pains to extend his medical network in the area, and so, offered key advice to those in the session, as well suggesting ways in which fraud could be prevented in the future.

He noted that having a doctor present as part of the mountaineering team, or at least visiting the Everest ER at base camp, would help to ensure that a helicopter is called out for the right price, and that the correct medical response is provided for each individual case. He also advised placing doctors on medical flights, as well as along the popular trekking routes.

Ultimately, Dr Dhillon concurred with Carol Foley’s view on collaboration when it came to fighting helicopter fraud in Nepal. “As with all fraud, if we can share this information, then we can progress. Finding a way to share best practice in fraud in a commercially effective way is key,” he said.