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THE COMMON TYPES OF HEALTH INSURANCE FRAUD AMONG INSURED AND HEALTHCARE PROVIDER

Prof. Dr. Sharifah Ezat Wan Puteh and Abdulaziz Abdullah Al Salem.

Insurance fraud ranks second only to tax evasion as the costliest white-collar crime in America. The main motive in health insurance fraud is financial profit. Insurance contracts provide both the insured and healthcare provider with opportunities for exploitation. In health insurance, fraud‚ false or misleading information is provided to a health insurance company in an attempt to have them pay unauthorized benefits to the policy holder‚ another party‚ or the healthcare provider. The offense can be committed by the insured or the provider of health services. The review result shows that the health insurance fraud has a negative effect on the annual return on assets (financial performance) of insurers, and on the society, and has several types of fraud. When fraud in the health, life and specialty insurance lines is added, insurance fraud costs could exceed $100 billion a year. Keywords: Types; Health Insurance; Fraud; Insured; Healthcare provider.

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