Computerised medical claims pick up fraud and drug abuse

Most claims to Daman are now vetted by a new computer system that the country's largest health insurer says will help it spot fraud.

Dubai // Most claims to Daman are now being vetted by a new computer system that the country's largest health insurer says will help it spot fraud. Every hospital and clinic in Dubai and Abu Dhabi now submits its bills on an electronic form. A computer programme monitors the claims, and triggers an alarm when it sees suspicious patterns.

Among the things it looks for are patients who visit several doctors in a short space of time, a practice known as "doctor-hopping". This, Daman says, can indicate prescription drug abuse, or clinics billing for non-existent patients. Dr Jan Aoun, the insurer's chief medical officer, said 90 per cent of the claims submitted by its 1.8 million customers are now handled by the electronic system. The rest, he said, are from the Northern Emirates and abroad.

"It is much more difficult for someone to abuse the system, because the electronic process will spot something suspicious," he said. "It doesn't mean that every suspicion is fraud. Not all smoke is a fire." With paper claims, information is stored in several places, making it difficult and time-consuming to spot patterns, he said. By contrast, "the electronic system will immediately show if, for example, someone puts in a claim one month for a tooth removal but sends a bill the following month for a filling on the same tooth".

Dr Aoun said the system would also notice behavioural patterns, such as patients who visit doctors at the same time every month. "It could be that he is seriously ill, but it is something we will investigate," he said. The system has also reduced paperwork, allowing the company to process claims more quickly. By contract, Daman has 30 days to pay private insurance claims, and 45 days for claims through the Thiqa programme, the Daman-operated system for nationals. "We are now hitting 97 to 98 per cent of these targets," Dr Aoun said.

It is not clear what the reimbursement times were previously. The first section to go fully electronic was Thiqa, which started taking e-claims in 2008 and completely moved to the new system in September. "It has taken time to get everyone familiar with all the codes for the electronic claims," Dr Aoun said, adding that there were more than 20,000 categories. "The western market took years to get used to them."

He said the system would also make it easier to track the spread of illnesses. Information on cardiovascular disease and diabetes, for example, could be used by Daman's disease management team to offer mentoring and advice to patients. @Email:[e-mail]