Healthcare fraud is usually perpetrated by healthcare providers, patients, and others who may want to deceive health insurance companies to receive unlawful benefits or claims. 

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For context, health claim fraud in Nigeria typically happens when false or misleading information is provided to a health insurance provider in order to make them pay unauthorized benefits to the policyholder, a 3rd party, or the entity providing healthcare services. 

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This is not an isolated case in Nigeria or Africa, it is one the most infamous insurance frauds globally which can be committed by healthcare practitioners, the insured or dubious 3rd party agents.

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Common Fraudulent Health Claims in Africa

Over the years, the following have been identified as the most rampart healthcare frauds that have created serious challenges for the National Health Insurance Scheme (NHIS) in Nigeria:

• Double billing by healthcare providers
• Billing for healthcare services not provided
• Health claims by ghost patients
• Identity theft to process health claims
• Collusion with providers and kickback collection

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Impact of Health Claim Fraud  

Healthcare fraud robs off negatively on everyone - insurer, the insured, healthcare providers, and Healthcare Management Organizations (HMOs). It leads to huge loss of funds that could have been used to cater for genuine claims, higher medical costs and more expensive insurance premiums for an average Nigerian.

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For health insurance providers, fraudulent health claims inflate their payouts and put pressure on your overhead costs. With an unfair increase in overhead costs, insurance companies tend to suffer decline in profitability and productivity. 

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Detecting and preventing healthcare fraud

Trying to detect health claim fraud with manual insurance management processes is quite difficult for three major reasons which are:

1. Patients with health insurance are shielded from actual medical costs, and they’re not necessarily equipped with the knowledge to detect fraud and waste. 

2. Different healthcare providers and HMOs have different processes which creates lapses that are usually exploited for fraudulent claims

3. Insurance providers who rely on analog claims management processes put up with tedious reconciliations that subject them to more fraudulent claims being paid out. 

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Apart from the tedious processes, the common traditional methods of detecting healthcare fraud and abuse are time-consuming and inefficient. As an upgrade to this manual insurance management process, some health insurance companies use a statistical method driven by secondary data tracking which is known as Knowledge Discovery from Databases (KDD).

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Data mining is a core part of the KDD process. It helps third-party health claim payers to extract useful information from thousands of claims and identify a smaller subset of the claims or claimants for further assessment. 

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However, some KDD-based fraud detection methodologies merely focus on algorithmic data mining without an emphasis on or application to fraud detection efforts. This means they are not tailored to the unique nuances of health service provision and variety of health insurance policies. This is another inefficiency that emerging insurTech solutions are solving.

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In Nigeria and Africa today, forward-thinking insurance companies are turning to more advanced technology solutions for fraud detection and prevention. AI-driven insurance technologies like Curacel, leverage extensive data analytics, artificial intelligence and machine learning algorithms to analyze large data sets to determine when and how fraudulent activity is likely to occur. 

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AI-based claims management solutions have proven to detect fraudulent health claims with almost 90% accuracy or more, in some instances. 

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Curacel's Claim Detection is a powerful, artificial intelligence-based health insurance fraud detection solution delivered as a Software-as-a-Service (SaaS). It helps insurers identify and prevent potentially fraudulent insurance claims, performing up to 12 times better than any in-house fraud detection systems and resulting in approximately 25% lower payouts.

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With Curacel Detection, insurers can view a comprehensive list of vetted claims, with indicators for flagged claims, falsified medical history, exaggerated loss, faked incidents, etc., all on a single, user-friendly dashboard. This makes it easier for claims handlers to conduct thorough quality assurance.

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Curacel health claim fraud detection software insurance companies in Nigeria, Africa and emerging markets to:

• efficiently save overhead costs and optimize payouts
• speed up adjudication and claims vetting process by 90%
• prevent claims management backlogs which often trigger human errors
• improve claims processing with actionable insights from transaction data

Speak with our team of experts, get started now.