The health ecosystem, in India, is witnessing a transformation. Health insurance is the fastest growing line of business in the insurance space to provide health care finance to a wide range of population.

The government of India moved from a sectoral, segmented & fragmented approach to health care delivery through various State/UT schemes converged with the flagship health insurance program Ayushman Bharat (PM-JAY) with more comprehensive and need-based service delivery of secondary & tertiary care to achieve Universal Health Coverage as its Sustainable Development Goal-3 (SDG3).

Worldwide, it is a recognized fact that health insurance schemes are prone to fraud, abuse, leakage & wastage which not only impact the schemes financially, but it also often led to endangering the health of beneficiaries of such schemes. Information asymmetry, as well as fraud and abuse either from the demand side or from the supply side of health care, makes the transactions related to health care treatments very complex. In such a scenario it is important to prevent, detect and deter fraud through efficient and effective processes on a real-time basis with the help of skilled professionals. Medical necessity is at times compromised for commercial interests and excess or not necessary care is provided despite the availability of Standard Treatment Guidelines (STGs) and Minimum Document Protocols (MDPs) specific to Health Benefits Packages (HBPs) designed for various health care schemes. This gap generates the demand for various types of Investigations and Audits to verify and validate health episodes & related transactions.

The Health Administrators of various State Health Agencies, Health Insurers, Third Party Administrators servicing health insurance schemes and policies, Brokers handling Employee benefit schemes, and Independent Investigators & Medical Auditors require guidance tools to aid their investigations and medical audits to detect frauds and abuses prevalent in popular schemes and retail products.
This book systematically covers all those areas that focus on the skill improvement of professionals working with stakeholders as well as those engaged independently to prevent and detect frauds and abuses in health insurance transactions. It comprehensively covers best industry practices right from principles and practices of health insurance and procedures whilst taking any treatment not limited to pre-authorizations for cashless treatments, medical document process, and various investigation and audit skills to address the gaps pointed out and observed by the stakeholders in the documentation of reported claims or process of such claims. The contents provide tools to aid in writing structured reports and collecting proper documents and complete evidence to deal with the suspicious transactions to find whether the triggers are ‘True-Positive’ or ‘False-Positive’. It deals with various roles of Field - Investigators during field investigations and the professional roles of Medical Auditors to ensure efficient and quality service in the case of field investigation and Medical Audit.

This inclusive book is designed to cover all crucial aspects from the concept of investigation to the fundamentals of health insurance and the relevance of evidence in the investigation process. It covers the aspect of medical necessity to guide medical auditors. It covers the health information system of hospitals to understand the necessary medical documents for providing treatment. The chapters related to handling and collection of evidence and the art of writing investigation reports are designed to develop the skills of Investigators and Medical Auditors who can significantly contribute to the capacity-building process of various stakeholders as a strong resource to their anti-fraud framework and can contribute to fraud mitigation process for various stakeholders, both in commercial and government health insurance space.