Mediclaim Investigation


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A Medical Investigation is a process that detects fraud medical claims Insurance companies, insurance examiners, and investigators all use the Claims Investigations procedure to gather information in order to evaluate a claim. As a result, it may be necessary to look through papers, locate witnesses, visit and interview people, and investigate property such as accident scenes, and physical locations.

We are part of the ISO – Quality Management System, as well as an in-house investigation team of 20-25 investigators, made up of doctors and paramedics, as well as impaneled investigation agencies across the country, to look into all suspected fraud claims. This Process lays forth broad parameters to help us identify and eliminate prospective cases for investigation from any allegations we receive. Apart from well-defined triggers for need-based inquiries, some fraud-prone categories of claims are required to be investigated. Our in-house medically qualified claims processing professionals combat suspected fraud by rigorously analyzing/scrutinizing the data given in the claims reported. Anomalies are reported to the Investigation Department whenever they are discovered. The Investigator then visits/discusses with Hospitals/Claimants to ensure the right inference before disposing of/denying the claims.

The investigation of Health claims and Life claims (Cashless/RIM/TTD/PTD/HDC/PA cases) which are found suspicious during the claim processing. Our advanced technology and experts help to identify fraud cases during the investigation process. Our aim is to eradicate the medical claim fraudulent cases during the investigation process. our work is to gather the required information from health care providers (Hospital, Treating Doctor, concern path, labs and any related authorities) to find out the Genuity of the claim, any past medical history of the patient, any misrepresentation in given documents. Our finding and observation help to the insurance company to take further decision for processing the claim.

For Example – Photographs, video, locating witnesses, interrogating victims, etc. are all possible outcomes of these investigations. Investigators are looking for evidence to determine if a claim is legitimate or not. Other claim-related services indicated in this section may also be necessary to obtain such answers.

Types of Investigation –

1. Cashless Claim Process –

Cashless, as the name implies, relieve you of the pain of dealing with large amounts of cash. So, how do you make ends meet? As an insurance provider, you must supply the hospital with your insurance information in order to use their services. Physical proof or an e-card issued upon the purchase of medical insurance coverage could be used. The hospital accepts your request to treat you and processes your claims based only on these proofs. The ailment for which you have been admitted, on the other hand, must be covered by your insurance plan. The hospital is responsible for forwarding all bills to your insurance carrier after you are discharged from the hospital.

As soon as the hospital receives these bills, the relevant departments thoroughly examine them to determine the nature of the expense and settle the payment so that all outstanding debts are paid. Payment instructions go between the hospital and the insurance company in this process, which is known as a cashless settlement. You don’t have to keep track of your bills or worry about how to pay your medical expenditures if you have insurance.

2. Claim Through Reimbursement Process –

This one is a little more complex for the insured because they must claim it from the service provider after they’ve been discharged. To put it another way, you pay your bills first and then apply for reimbursement later to get the full amount back. It is not necessary in such instances for the hospital where you seek treatment to be a network hospital. Walk into any hospital that can cure your sickness and keep your payment receipts safe. In this instance, however, you cannot use the cashless claim process because it is null and void.

After the claim is checked and determined to be valid, it is processed quickly and painlessly, and the money is made to the insured’s registered bank account. However, if the payment is rejected owing to a condition, the insured is alerted via customer service channels. It could come in the form of an email, a letter, or even a phone call from the claim-processing department..

Ten Common points on which basis claim identify as suspicious
  1. Claims within 60 days of policy inception date /policy end date
  2. Single insured and high value claim
  3. Prolonged hospitalization as per diagnosis.
  4. Any critical illness and policy are within 01-02 yr./ If the patient’s age is more than 50 yrs. and admitted for heart / kidney /liver diseases
  5. Supporting investigation report is not submitted
  6. Medicines charges is more than 40-50 percent of total claim
  7. If the total hospitalization bills are more than 02 lakh and paid in cash
  8. All the indoor case paper is in same handwriting / overwritten noted /hand written bills
  9. Rule out to alcohol/drugs influence in accidental case
  10. Same types of claims from same hospital/ same location

Why do we investigate insurance claims?

The purpose of the investigation is to prevent the fraud activity/rule out the miss presentation /understand the trends of fraud / Identify the nexus /Control the overbilling/unnecessary hospitalization /Rule out medical co-morbidities and adversity so that the cost of the company can be saved

After all, the paperwork has been properly examined and processed, and the claim is considered complete. The final step is to credit the entire claim amount to the insurer’s account, which you choose when you purchase health insurance.