The increasing number of fraudulent medical claims has emerged as a challenge for insurers and experts say electronic prescriptions plus data sharing platform can help tackle the problem.
In a meeting with representatives of insurance companies and market experts, Risk News website reviewed the challenges facing the key medical insurance sector.
Participants concurred that fake claims/prescriptions and unhealthy competition are the main challenges insurance companies are grappling with.
Majid Garshasbi, an insurance expert said the number of fake medical claims is on the rise along with fake prescriptions. "Fraud cases in the medical category now outnumber those of third-party auto insurance," Garshasbi complained.
"It is believed that fraudulent cases account for 15% of the total cases in Iran. Electronic prescription could help reduce this considerably."
He noted that lack of a central data collection platform had indeed led to this unacceptable state of affairs. "Insurance companies need to start sharing policyholder data…Analyzing data can go a long way in controlling healthcare fraud.”
He also referred to unhealthy competition in the medical insurance sector. "As per law, insurance companies should settle medical insurance claims within 15 days. Some companies publicize that they can settle claims in five days but in practice fail to do so."
Medical claims accounted for 33.9% or 22 trillion rials ($786m) of the total payouts that year, up 86%. Insurers paid claims in almost 49 million cases accounting for 93% of the total claims
By failing to meet their declared commitments insurance firms “harm the key sector simply because if this pattern continues insurers would never be able to win back the trust of the people and hospitals.”
Medical insurance was the industry’s second earner in the last fiscal year (March 2021-22) with 18%. Companies sold 1.23 million medical insurance making 21 trillion rials ($751.1 million) accounting for 1.73% of the total sales, and premium income in this category was 34% higher on the previous year.
Medical claims accounted for 33.9% or 22 trillion rials ($786m) of the total payouts that year, up 86%. Insurers paid claims in almost 49 million cases accounting for 93% of the total claims.
Covis-19 put insurance companies in a tight spot. Soon after the pandemic spread in 2020, insurers were ordered by the government to broaden the scope of medical insurance to cover costs of the deadly coronavirus, including medicine approved by the Health Ministry.
Despite the devastating impact of the deadly disease, insurers saw the pandemic as a rare development that allowed them to improve their tarnished credentials with customers who rightly complain about their strange practices, mainly in the main private hospitals, in demanding full payment of bills and refusing to deal with the bureaucracy of insurance companies and other hassles.
Mojtaba Atri, a board member of Dana Insurance Company, believes that insurance companies need to develop a shared interest in supervising operations in the key segment. "Insurance companies can share records and create a list of fraudulent policyholders to suspend services to them."
He called on the Ministry of Health and the Central Insurance company of Iran to further promote the electronic prescription system.
Electronic prescription is the computer-based electronic generation, transmission, and filling of a medical prescription, taking the place of paper and faxed prescriptions.
E-prescribing allows a physician, physician assistant, pharmacist, or nurse to use digital prescription software to electronically transmit a new prescription or renew authorization to a community or mail-order pharmacy.
