Daman uncovers medical fraud

Investigation uncovers "a number" of cases of medical clinics and pharmacies committing insurance fraud.

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ABU DHABI // An investigation has uncovered "a number" of cases of medical clinics and pharmacies committing insurance fraud, which could drive up premiums. Physicians have claimed for treatments and tests they did not perform, while pharmacists have dispensed drugs different to those on prescriptions, according to Daman, the Abu Dhabi-based national insurance company, which launched the "mystery shopping" investigation.

It is understood that this is the first time the mystery shopper method has been used in the UAE's insurance sector. Dr Michael Bitzer, the chief executive of Daman, said in the company's statement that the clampdown was launched to prevent the fraudulent practice from raising premiums. "It is our duty to protect our customers' best interest," he said. "Fraudulent claims that go undetected will affect the underwriting process and ultimately result in unfairly increased premiums for our customers."

Daman's mystery shoppers found that "one provider filed false information with respect to the patients' symptoms, medical history and diagnoses as well as claiming for excessive tests and treatments that were not conducted", the statement said. The investigation by members of Daman's medical audit team "also uncovered a number of fraudulent cases where pharmacies have switched prescriptions based on patient requests and dispensed alternative products and cosmetics that are not covered by their insurance plans", it said.

Some of the physicians and pharmacists found to be committing fraud were issued warning letters telling them the matter would be referred to the Health Authority -Abu Dhabi. Some were also taken off the list of providers operating with Daman. This means they will no longer be able to claim money from Daman, which currently holds around 80 per cent of the market in the capital. Daman did not disclose how many cases have been identified or how long its mystery shoppers had been operating.

"Insurance fraud is a very serious criminal offence that is not to be taken lightly," said Dr Jan Aoun, the chief medical officer at Daman. "Daman has imposed penalties on implicated providers and has also launched a full investigation to combat such fraud. Dr Rainer Petzel, the head of the legal department at Daman, added: "Health insurance fraud occurs across the world; through our medical audit unit we are attempting to control and minimise the levels of fraud and abuse within the UAE."

The Health Authority - Abu Dhabi has the power to suspend or revoke licences of anyone found to be committing insurance fraud. Daman announced in February that it was cutting dental cover for Emiratis in private clinics by half because of a large number of violations. Emiratis now have to pay 50 per cent of the dental costs under the Thiqa programme, which has half a million members, unless they are treated at public facilities.

Thiqa, which covers all health care for Emiratis, is administered by Daman. Dr Aoun said the insurer had become aware of a number of dentists recommending the most expensive treatments, some of which were not necessary, to "inflate the bill". An investigation by The National identified three dentists offering treatments varying from Dh300 to Dh41,010 to the same patient in the same week. Since the introduction of mandatory health insurance in Abu Dhabi in 2006, private clinics must claim per treatment from the insurance company, rather than receiving an unlimited amount of money from the Government.