5 tips for preventing fraud in Health Insurance

Health insurance is one of the best ways to guarantee access to medical and laboratory services for your company’s employees . However, some care is needed to ensure prevention of fraud that may surround the use of these services.

Irregular situations that promise ease are, in fact, a trap that can cost the insured dearly. Maintaining compliance with contractual provisions is the best guarantee of security.

Want to know more? Continue reading and learn 5 tips for preventing health insurance fraud.

Health insurance and its main features

Insurance, in general, is support services provided in the form of compensation, repair or reimbursement, contracted under defined conditions. Payment by the insured is made in the form of a premium, usually divided and paid in monthly installments.

Health insurance, in turn, is paid in the same way and support is provided by reimbursements for expenses incurred by the insured person with health care. It can be seen that health plan and health insurance do not constitute the same assistance instrument.

The main differences that insurance presents in relation to the plan are:

  • payment for services (consultations, exams) on demand;
  • partial or full reimbursement of expenses incurred;
  • professionals and establishments of the insured’s preference.

Thus, it is clear that, in the health insurance model , the insured person is the one who pays for medical and laboratory services. It is certain, however, that you will later be reimbursed in accordance with the terms contracted in the insurance.

5 tips to prevent health insurance fraud

Fraud is illegal acts or acts carried out in bad faith, in order to obtain undue advantages. Fraud can be carried out for the benefit of oneself or third parties, among others, through initiatives such as:

  • practice of omission;
  • manifestation of untruths;
  • intentional non-compliance or circumvention of existing rules;
  • Power abuse;
  • breach of trust.

Below are 5 important tips to prevent health insurance fraud. Follow along!

1. Be wary of offers with very low prices

Only insurance companies duly authorized by the Private Insurance Superintendency can offer insurance on the market. Marketing is carried out by insurance brokers , whether individuals (the professional broker) or legal entities (insurance brokerage companies). Health insurance is regulated by the National Supplementary Health Agency (ANS).

Informing yourself about this is important, as there are institutions on the market offering, irregularly, different types of protection. As they are not registered with Susep, they are also not regulated, acting on unsuspecting people and companies. Therefore, be wary of insurance offers or promotions when they offer prices well below the market.

2. Consider that aesthetic treatments are not covered

Law No. 9,656/1998 (Health Plans Law) exempts insurance and health plans from covering procedures for aesthetic purposes, whether clinical or surgical. This means that treatments aimed at aesthetics and not linked to any disease are not covered by the clauses of health insurance.

This is an issue pacified in judicial decisions in the face of disputes that are sometimes pleaded. Therefore, it is not an initiative that can be considered and, therefore, do not adopt it.

3. Don’t share login data

For you to use online service, there are two most common routes: the insurance company’s website and your health insurance app. In any of them, you must be properly registered and have specific login details (username and password).

This data is completely confidential and you should not, under any circumstances, share it with anyone. Firstly, because only you can use your insurance and someone else doing so constitutes fraud.

But there is another reason: when you share confidential data, regardless of who it is with, your vulnerability greatly increases and, as a result, the occurrence of fraud by third parties. Therefore, keep your login exclusively for your personal use.

4. Do not allow your receipts or service invoices to be divided

During the term of the health insurance , you choose the doctor, laboratory or health establishment where you want to be treated. Once the service is completed, you make the payment yourself and request the respective receipts or invoices.

Do not allow these services provided to have their scores divided into different services. Needs for serial treatments, with several sessions, as in the case of physiotherapy, for example, should only be mentioned in those actually used on the day.

Irregular procedures of this nature can classify those who issue and those who receive split notes as fraudsters. Please note that your refund must strictly follow the provisions of the signed contract.

5. Know that your health insurance is non-transferable

As previously mentioned, the use of health insurance is exclusive to the insured person. Therefore, if you have taken out health insurance for yourself, do not allow anyone else to use it, as insurance coverage is non-transferable.

Always keep in mind that unlawful behavior can result in the termination of your health insurance, as well as financial damages. If you have any issues about reimbursement, please contact your insurance carrier.

What to take into account when taking out health insurance

To take out any type of insurance, the best way is to contact your insurance broker. She will be your guide and provide the necessary guidance to meet your real needs.

In fact, your broker is able to find the best options on the market for you to make your choice safely and stay well informed. All of this applies the same to health insurance.

To facilitate understanding, consider the following guidelines for purchasing health insurance for your company:

  1. Identify the company’s real needs.
  2. Contact your insurance broker.
  3. Request a quote.
  4. Provide all requested information.
  5. Evaluate the options presented.
  6. Make your choice based on the demands raised at the beginning of this process.

As you can see, care to prevent fraud in health insurance needs to be adopted firmly, not allowing alleged facilities that can lead to the loss of insurance and significant losses for everyone involved. In turn, finding an experienced and trustworthy insurance broker will make all the difference, making it easier for the company to take out the health insurance that best suits the organization’s profile.

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