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The presence of healthcare fraud, waste, and abuse is one of the topical and complex problems of the modern healthcare system. It includes illegal healthcare benefits, overutilization of services, and engagement in activities that are “inconsistent with professional standards of care, medical necessity, or sound fiscal, business or medical practices.”1 In the context of this paper, fraud and abuse represent pervasive cases of unnecessary medical care and insurance services or fraud in the purchase of an insurance product recommended by different organizations.
Even though the majority of medical professionals and consumers are honest, there are people cheating on the healthcare system to gain benefits. As a result, many countries take measures to detect and prevent such practices to keep healthcare costs within reasonable limits. This report is aimed at an overview of the rules and regulations of health care fraud and abuse in Saudi Arabia.
The Fraud Management Strategy
Anti-fraud and abuse regulation are the common principles and standards that should be followed by healthcare organizations and insurance-related service providers to prevent and minimize the occurrence of this problem. Insurance fraud and abuse manifest in misappropriating assets, deliberately misrepresenting and concealing financial facts, perception of the insurer’s status, and overuse of authority. Saudi Arabian Monetary Agency distinguishes three overarching categories of fraud and abuse in the healthcare area: internal (perpetrated by employees), intermediary (by insurance service providers), and policyholder fraud (in the purchase of an insurance product).2 In Saudi Arabia, a set of rules has been developed according to the types of these violations to regulate and resolve the issue.
To combat fraud and abuse, consumers need to know how to protect a health insurance card, report lost or stolen cards, refuse to sign suspicious documents, and find out more information before performing questionable actions. Every organization providing medical and insurance services should establish appropriate monitoring and enforcement of all rules, standards, and laws to detect and eradicate fraud and abuse. In obedience to the fraud management strategy of Saudi Arabia, the organizational structure must facilitate communication between staff, department heads, and senior management and also provide a suitable environment for the execution of the strategy.3 Healthcare organizations may conduct complex anti-fraud and abuse training, in which scope and content vary depending on the role and responsibilities of staff.
The Rules and Regulation in Saudi Arabia
Saudi Arabian organizations define clear and well-documented policies and procedures to measure internal fraud and abuse committed by the board members, management, and staff in any of the healthcare activities. Regulation can be observed in setting up security measures over the availability and use of cash and information systems and restricting access to computer server rooms, cash transfers, and electronic transfers. Companies monitor access rights to networks, renew passwords on a regular basis, and implement web security.4 To prevent fraud and abuse, they enforce management and staff supervision policies, and also, before hiring personnel, organizations may perform background checks of potential staff.
Service provider fraud and abuse are also widespread in the area of healthcare; thus, it is necessary to detect internal and policyholder fraud and monitor insurance service providers. Internal auditors must assess the fraud risk in a report, which contains a review of the business, an assessment of trends and occurrence of fraud, and an overview of the insurance processes. Insurance companies should provide a well “documented screening procedure for the appointment of new insurance service providers.” 5 They also may require applicants to disclose relevant business information to evaluate the reputation of potential insurance service providers and assess their financial situation. To reduce fraud and abuse, insurers need to avoid paying a commission before the first premium is collected, keep parts of the commission in a temporary deposit account, and send documents directly to policyholders.
According to regulation in Saudi Arabia, healthcare companies implement procedures to fight policyholder fraud committed at the policy setup and claims filing stages of the client relationship. Organizations make records of the occurrence of policyholder fraud, which detail the type of fraud, the technique used to commit the fraud, and the weaknesses in internal control procedures.6 Moreover, they define and document client filtering policies and set the necessary conditions to accept new clients. Companies define clear claims assessment procedures and inform policyholders about their processes and the consequences of providing false information. Altogether, they should create their policies, implement new anti-fraud and abuse procedures, and improve existing ones.
To sum up, healthcare fraud and abuse is a pervasive problem of the modern healthcare area, which requires an integrated approach to its solving. In healthcare systems around the world, this issue leads to financial losses not only for insurers but also for employers and consumers. Rules and regulations in Saudi Arabia promote high standards of fraud and abuse detection in order to regulate and prevent this illegal activity. For each category of fraud, comprehensive solutions have been developed; however, there are some general principles such as protecting health insurance cards, reporting any lost or stolen cards, or refuse to sign suspicious documents.
Concerning medical organizations, they should establish appropriate monitoring and enforcement of standards, facilitate communication between staff, and conduct sophisticated anti-fraud and abuse training.
Saudi Arabian Monetary Agency. Anti Fraud Regulation. Insurance Supervision Department, 2008.
Willis Limited. Healthcare Fraud, Waste and Abuse. London: Willis, 2015.
- Willis Limited, Healthcare Fraud, Waste and Abuse (London: Willis, 2015), 3.
- Saudi Arabian Monetary Agency, Anti Fraud Regulation (Insurance Supervision Department, 2008), 4.
- Saudi Arabian Monetary Agency, Anti Fraud Regulation, 8.
- Saudi Arabian Monetary Agency, Anti Fraud Regulation, 10.
- Saudi Arabian Monetary Agency, Anti Fraud Regulation, 12.
- Saudi Arabian Monetary Agency, Anti Fraud Regulation, 14.