Saudi Gazette report

RIYADH — Insurance companies have reported that fraud was responsible for a 25 percent increase in rejection of medical claims submitted on behalf of patients.

Insurance experts said fraudulent practices ranged from charging companies costs not covered by companies to conspiring with doctors to submit fake claims.

They warned patients or service providers who exploit the insurance system by manipulating bills will not escape legal accountability and could be charged with fraud and forgery.

They said cases of manipulation and exploitation reflect primarily on the high prices of medical insurance in the Kingdom.

Insurance specialist Dr. Fahad Al-Enezi said, “Exploiting medical insurance by over-prescription of medicines and laboratory investigations, billing of services not covered in basic policy is common in all regions and countries of the world.”

Al-Enezi said there were cases of abnormal exploitation of health insurance by individuals and companies. He said the doctor or the management of the service provider is the main link in such cases, he added.

Insurance expert Maher Al-Juairi said the manipulation in some hospitals can be inferred from the high rate of claim rejections, which sometimes can go up to 25 percent of the value of claims.

Al-Juairi said the poor performance of insurance companies and the weakness of control are the reasons that lead to manipulation.

“Manipulation exists on all sides, but if there is some controls that limit manipulation in some categories, the service providers’ position would have been stronger and the rate of rejections would have dropped. The best proof is fingerprinting to confirm the identity of patients,” he said.

Al-Juairi points out that insurance companies have taken several steps and means to protect against exploitation and fraud, including examining claims before approving treatment.

Al-Juairi called on the Ministry of Health to take practical measures to reduce the manipulation. At the same time, he pointed out that hospitals that serve insurance patients have increased their prices to offset costs.

The Council of Cooperative Health Insurance confirmed that the approved health insurance policy currently covers all expenses of medical examination, medicines, lab tests and x-ray, in addition to the expenses of surgery. The maximum limit of coverage is normally SR500,000, including expenses for diagnosis, treatment, medicines and hospitalization. However, there are a number of exceptions that are not covered by claims coverage, including cosmetic surgery except those caused by accidents, as well as diseases resulting from misuse of certain drugs, stimulants, sedatives or alcohol.