Cases of health insurance fraud have frequently appeared in the news. Big companies have noticed and taken action over the misuse of the reimbursement benefit, which can lead to considerable financial losses. This is what happened, for example, with Itaú and the CCR Group.
In total, almost 200 employees were dismissed at the two companies after internal investigations uncovered irregularities in reimbursement requests, such as charging for procedures that had not been carried out and were overpriced, as well as in the name of fake clinics. Both cases gained repercussions in the media.
Not only are companies taking action against the recent fraud cases, but insurers in particular are reinforcing their security schemes. In 2022, for example, the Brazilian Association of Health Plans (Abramge) prepared a booklet on preventing fraud. In addition, the National Federation of Supplementary Health (FenaSaúde) filed a complaint with the São Paulo Public Prosecutor’s Office about a possible fraud scheme.
It is worth mentioning that fraud committed by a worker can lead to serious consequences, such as suspension or termination of the contract for justified reasons, and it is up to the company to decide what will be done. In addition, they could also face criminal consequences and be forced to pay back the money they received illegally.
How to avoid claims fraud
In view of the increase in fraud cases, health plans have adopted a more cautious approach. It can take longer than usual to process a claim, and extra documents may be requested.
On the beneficiary’s side, it is necessary to be careful not to commit fraud unknowingly. To apply for reimbursement, you need to check with your health insurance provider whether this benefit is offered. In many cases, you can do this via the app, as well as ask for a preview of the amount to be reimbursed.
Reimbursement is compensation for medical expenses, including consultations, exams and other procedures defined in the contract. It can only be requested if the procedure in question has actually been carried out and paid for.
In addition, it is essential to check the credibility of the institution where the procedure was carried out. It is important to note that customers must not share their login and password information (which is personal and non-transferable) with service providers (hospitals, clinics, laboratories, among others) and reimbursement must only be requested by the beneficiary, after payment for the service. Be aware that providers cannot request reimbursement on behalf of clients.
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