PMI: Can fraud be beaten?

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With PMI fraud hitting the headlines, Nicola Culley investigates the size of the problem.

AXA PPP is currently investigating suspected international private medical insurance (PMI) fraud of “considerable size”. It sits against a backdrop of insurer fraud prevention teams, across the industry, that have swollen in recent years amongst awareness of the problem.

The insurer, often touted as one of the most active insurers in tackling PMI fraud, started with a full-time fraud team only as recently as 2003. The team has now grown to seven full-time staff, led by Dr Simon Peck, head of investigations. It comprises a mixture of clinical and claims payers, with support from lawyers and external contractors.

AXA PPP  has a customer service fraud team, too, but this type of fraud is not a big issue, according to Peck, because AXA PPP pays most bills direct to healthcare providers. However, he says there are a few problems, for example, where customers collude with doctors to obtain funding for cosmetic treatment that is not covered by insurance.

Peck adds that the stand-out area for fraudulent activity currently was internationally. He says: “In the international arena, there is currently a suspected fraud of considerable size under investigation. The biggest changes we have seen are in the international arena, where insurers are more vulnerable to fraud.

“There is growing cooperation between insurers, and this is leading to us discovering more problems, but more importantly developing new solutions. What is most heartening to me is that we have cooperation between insurers, not only in the UK but also in the US, all of whom are working together on this.”

Cost of global healthcare fraud

The UK also has an organisation dedicated to promoting such cooperation: the Global Healthcare Anti-Fraud Network. Estimates of the cost of healthcare fraud vary widely. The European Healthcare Fraud and Corruption Network published some indicative figures suggesting rates of between 3% and 15% across the world.

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