Star Health and Allied Insurance say its anti-fraud mechanism — medical experience embedded with technology — has helped the standalone health insurer achieve some savings in its claims outgo while taking action against errant hospitals that claimed fake bills.
“We have moved from a manual process of claims to a digital technology-enabled system,” Dr S Prakash, Managing Director, Star Health told. “With our experience in the medical field, we have developed a very robust rule engine for claims. Multiple checks have been put in place to identify irregularities,” he said. While Star Health recognise good hospitals, it has also taken action against “errant hospitals” for malpractices and serious frauds,” he said.
In FY22, the company blacklisted about 1,185 hospitals for fake claims and suspended the cashless option for about 230 hospitals. In FY23, it blacklisted more than 1,300 hospitals, while suspending the cashless mechanism for 300-odd hospitals.
The reasons for blacklisting and suspension of cashless include impersonation, fake claims, phantom billing, duplication, resubmission of rejected claims by others, claims under different names, poor infrastructure, bad clinical governance, etc.
“These fake claims are being raised for the insured people, imagine what will happen to those poor or uninsured people who go to these hospitals. Because of few black sheep, there is a large stress in the industry,” he said.
