Large-scale fraud has become a recurring challenge for supplementary health. According to the Agência Nacional de Saúde Suplementar (ANS), Brazil’s regulatory agency for supplementary health, operators lose around BRL 28 billion per year to fraud and waste, an amount that represents approximately 19% of the sector’s healthcare costs.
But the consequences of these losses go beyond financial damage. The diversion of resources prevents investments in infrastructure, technology, professional training, and improvements in service quality. In the end, everyone pays the price.
In this article, we’ll show you the main types of fraud in supplementary health and the best practices to fight them.
Keep reading!
Types of fraud in supplementary health
Fraud in supplementary health can be committed in various ways and by different agents, such as beneficiaries and service providers. See some examples below:
Beneficiary fraud
Main types:
- Reimbursement requests: beneficiaries submit reimbursement claims with altered or false information, or even for expenses that never occurred.
- Misuse of identity: the health plan holder allows other people to use their personal information to access medical services such as appointments, exams, and treatments.
Fraud committed by professionals and clinics
Main types:
- Charging for false or unnecessary procedures: doctors or other healthcare professionals charge for treatments, exams, or consultations that were not performed or not medically necessary.
- Referral in exchange for commission: doctors or other healthcare professionals refer patients to specific services, clinics, or laboratories in exchange for financial benefits.
6 consequences of fraud in supplementary health
The main consequence of fraud in supplementary health is financial loss. To compensate for the lost amounts, the operators increase the price of services. This results in more expensive health plans with more restrictions. Other factors also impact the sector:
- Reduced quality of care: the diversion of resources harms the quality of care and increases the bureaucracy of the services provided.
- Increase in medical claim denials: fraud generates a higher volume of payment denials due to inconsistencies in procedures.
- Increase in legal complications: companies that do not adopt effective fraud prevention measures may face penalties such as fines, lawsuits, and regulatory restrictions.
- Increased demand for care: the improper use of medical services overloads hospitals and clinics.
- Loss of trust in the system: beneficiaries and service providers begin to distrust the credibility of the supplementary health system, which may reduce adherence to private health plans.
- Lack of resources for infrastructure and equipment: fraud affects investment in resources such as the acquisition of modern equipment and the improvement of hospital infrastructure.
So, how can we combat fraud?
Fraud prevention in supplementary health
To prevent and identify fraud, supplementary health has intensified the use of technologies such as artificial intelligence (AI) and biometrics. See more details:
1. Biometrics and AI
Biometrics and artificial intelligence verify user identities with precision and audit the data collected. This allows only authorized individuals to access healthcare services, for example, resulting in safer and more efficient processes.
2. Continuous monitoring and auditing
Regular audits are important to ensure that processes are conducted with transparency and compliance. This checking identifies weaknesses in the system and carries out corrections before fraud can be committed.
3. Education and awareness for beneficiaries and providers
Some fraud cases occur due to lack of knowledge or the normalization of illegal practices. Educational campaigns can clarify how fraud impacts the sector and promote ethics and transparency among all parties involved in the system.
We know that fighting fraud is not a simple task, and the lack of effective mechanisms makes this challenge even greater. With this in mind, BioPass ID was developed to validate the identities of beneficiaries and service providers with security and precision.
Biometric APIs for supplementary health
In the face of fraud schemes such as overbilling in reimbursement requests, identity theft, and insurance card forgery, BioPass ID’s APIs meet the needs of health insurers. Discover some of the high-technology features of our solution:
- Biometrics for patient identification: BioPass ID provides tools to prevent patient misidentification, avoid duplicates in medical records, and ensure the integrity of the collected information.
- APIs for optimizing healthcare services: the platform offers multi-biometric API packages that ensure the security and modernization of healthcare institutions.
- Security and compliance: BioPass ID ensures compliance with the General Data Protection Law (LGPD) through advanced encryption and other security mechanisms.
With simple and reliable implementation, BioPass ID requires no prior knowledge of biometrics and can be integrated into various platforms and devices.
Keep supplementary health more protected with BioPass ID
As we’ve seen, fraud in supplementary health increases the costs of health plans, reduces potential investments in improvements, and leads to cost transfers to beneficiaries. To face this challenge, biometrics and artificial intelligence validate identities and protect the sector.
Together with frequent audits, technology makes processes more trustworthy and efficient. The BioPass ID Multibiometrics package significantly reduces fraud, enhances processes, and ensures service quality.
To request a free demonstration of the BioPass ID platform, speak with one of our specialists. If you’d like to acquire the solution, click here.
