Fraud in Medical Insurance

Medical insurance fraud is an intentional act by the cardholder, insured, and medical services provider to obtain not owed compensation or benefits to them or others through the deceiving, concealing, and/or misrepresenting information.

Forms of Medical Insurance Fraud

  • Using the medical insurance card by someone else.
  • Mislead to accurately report medical history & pre-existing conditions.
  • Asking for services, medicines, and/or procedures that are not provided, not covered, or for more expensive treatments or medicines than those prescribed.
  • Visiting same or multiple hospitals to receive unnecessary or duplicate medicines.
  • Forging prescription drugs.
  • Intentional abuse through exhausting the coverage limit at end of the policy or anytime.
  • Obtain unreal/unnecessary bills to get benefits for money reimbursement.

The Negative Impacts of Medical Fraud

  • Higher medical insurance premiums to meet the increase in the loss ratio.
  • Stop issuing medical insurance policies to reduce fraud claims and loss of access to insurance coverage.
  • Cancellation of the insurance policy.
  • Cease of dealing with medical service providers and thus deprive patients of distinctive treatment services.
  • Business financial losses resulting from fraudulent claims.
  • Claim rejection.
  • Lawful actions.
  • Health harm to the insured due to tampering with his medical history if the medical card is used by others

Medical Fraud Detection Methods

  • A dedicated Medical Fraud Unit.
  • Applying fraud control systems
  • Cooperation with regulators such as CCHI and/or SAMA.
  • A toll-free hotline which you can call to report suspected fraud.
  • A special Fraud reporting Email monitored by Fraud Unit Team

Your responsibilities to prevent fraud

  • Be aware of attempts by medical providers and others to convince you that everybody else is profiting so you may as well try to reap the benefits of insurance fraud.
  • To avoid unwanted medical procedures, always ask the doctor about the provided services and why you need them.
  • Do not allow anyone to use your medical card.
  • Carefully review your claims & bills before signing them, and question charges for procedures that were not provided.
  • Inform and call Tawuniya when you detect or suspect fraud.

Your reward for reporting medical insurance fraud

Tawuniya issued its policy and procedures to reward individuals and entities that assist in detecting and reporting the fraud acts.

Based on this P&P, a reward will be granted to the reporters after verifying the data provided and proving that they are fraudulent behavior or misuse of medical insurance services.

Ways to report medical insurance frauds

Report Medical Fraud

Tawuniya undertakes to maintain the confidentiality of the information of the person who is reporting the fraud in the medical insurance.

Frequently Asked Questions (FAQs)

What is Insurance Fraud?
Medical Insurance Fraud described as an intentional act of deceiving, concealing, and/or misrepresenting information that the cardholder or entity delivers, knowing that it could result in some unauthorized benefit or profit to them or to another party.

What kind of people/organizations commits insurance fraud?

Although anyone involved in the medical insurance process can commit a fraud, for example, card holders and Medical providers. In spite of that, Tawuniya still has its trusted and respected clients and business partners.

Insurance fraud is committed by people from all walks of life and in all occupations including individuals like Card Holders or employers/clients or Medical Providers.

What is Fraud Vs. Mistake?

It's important to distinguish between Medical insurance fraud/abuse and mistakes. Medical insurance fraud is an act of deception by misrepresentation of material facts, or silence when good faith requires expression, resulting in material damage to one who relies on it and the right to rely on it. Simply, it is obtaining something of value from someone else through deceit.

By contrast, mistakes are made unknowingly by anyone who lacks knowledge, in other words, it’s a misstatement or unintentional deviation from the truth.

Therefore, Tawuniya always recommend reading the Medical Insurance Guidelines and visiting Tawuniya social media accounts for more information about the ideal use of your Medical Card.

What are some examples of insurance Fraud/Abuse?
  • Using the medical insurance card by someone else.
  • Mislead to accurately report medical history & pre-existing conditions.
  • Asking for services, medicines, and/or procedures that are not provided, not covered, or for more expensive treatments or medicines than those prescribed.
  • Visiting same or multiple hospitals to receive unnecessary or duplicate medicines.
  • Forging prescription drugs.
  • Intentional Abuse through exhausting the coverage limit at end of the policy or anytime.
  • Obtain unreal/unnecessary bills to get benefits for money reimbursement.

How does fraud impact you?
As a result of insurance fraud, good hard-working individuals like you could be adversely affected in many ways. For example, you could be faced with:
  • Higher premiums.
  • Falsified medical history, in cases of identity thefts.
  • Non-payment of claims.
  • Cancellation of the insurance policy.
  • Business financial losses resulting from fraudulent claims.
  • Loss of access to insurance coverage.
  • Lawful actions.

What are we doing to prevent fraud?
Tawuniya continues to strengthen its systems and controls to ensure that fraudulent acts are detected and prevented to minimize the impact on honest customers like you. And we believe that it is also everyone's duty to aid in the fight against insurance fraud. Our anti-fraud procedures include:
  • A dedicated Medical Fraud Unit
  • Applying fraud control systems
  • Cooperation with regulators such as CCHI and/or SAMA
  • A toll-free hotline which you can call to report suspected fraud
  • A special Fraud reporting Email monitored by Fraud Unit Team

What is Medical Fraud Unit?
Fraud Unit is a department in Tawuniya responsible for investigating acts of potential Fraud/Abuse through Tawuniya’s fraud control systems and also, incidents identified by card holders, clients, medical providers, companies and other parties. Fraud Unit also cooperates on investigations with regulators such as CCHI and SAMA.

How can I prevent/avoid fraud?
You are a valuable member and source in our fight against medical insurance fraud. You can prevent/fight Fraud by reporting activities you suspect while visiting Medical Providers or anywhere else.
  • Inform and call Tawuniya when you detect or suspect fraud
  • Be aware of attempts by medical providers and others to convince you that everybody else is profiting so you may as well try to reap the benefits of insurance fraud
  • To avoid unwanted medical procedures, always ask the doctor about the provided services and why you need them
  • Do not allow anyone to use your medical card
  • Carefully review your claims & bills before signing them, and question charges for procedures that were not provided

Shall I get a reward for reporting medical insurance fraud?

Yes, anyone who reports a proven medical insurance fraud will be eligible for a financial reward according to Tawuniya’s rewarding policy & procedure.

How can I report fraud to Tawuniya?
If you suspect or see medical insurance fraud/Abuse, contact Tawuniya at:
  • Tawuniya hotline number 920019990
  • Or, email us at: fraudmed@tawuniya.com.sa
  • Or, via Tawuniya Website Reporting Form.
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