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Health care fraud continues to rise; know how to identify it

In 2023, more than 2,000 cases of health care fraud were recorded. In the aggregate over the last five years, the number rises to more than four thousand. The data comes from FenaSaúde (National Federation of Supplementary Health) and worries the sector, which has intensified the measures taken to combat this criminal conduct.

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According to the federation, the problem has intensified during the Covid-19 pandemic, caused by the increased use of digital technologies. Refunds have been identified as an important vulnerable area for these fraudulent activities.

Fraud can take place in a number of ways:

  • Forgery of documents to obtain coverage or medications unnecessarily.
  • Providing false information about medical history or pre-existing conditions to obtain coverage.
  • Misuse of health insurance card by another person.
  • Fraudulent referral for unnecessary medical procedures or tests.
  • Splitting medical receipts.
  • Forging medical prescriptions to obtain unprescribed medications or treatments.
  • Creation of fake websites to issue or modify health insurance invoices, virtual scam.

Committing health insurance fraud can result in serious consequences. It is considered a crime in many jurisdictions, which can lead to criminal proceedings, resulting in fines, imprisonment, or other legal penalties. Additionally, the individual committing fraud may lose the benefits of the health insurance, including medical, dental coverage, and other essential services.

In more severe cases, the health insurance provider may permanently exclude the person who committed fraud. This exclusion can result in serious difficulties accessing medical care and treatments in the future.

Finally, it is important to mention that the person committing fraud may be obliged to reimburse all costs incurred as a result of the fraud. This includes undue payments made by the health insurer and any costs associated with the investigations carried out to establish the fraud.

In short, the consequences of fraud are diverse and can have a significant impact on the life of the person involved.

Fraud jeopardizes the operation of health insurance and causes significant financial losses. It is essential to take constant action to maintain trust in the sector. Although most users and providers are honest, it is essential to involve society in the fight against fraud. In addition to awareness campaigns, operators use all available resources to investigate and prevent these practices that are harmful to everyone.

Here at Pryor Global, we have extensive experience in providing corporate benefits, including health and dental insurance. You can count on us to offer your employees the best available options in the market. Let’s talk?

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