Introduction
Today, numerous companies are experiencing problems resisting illegal actions and suffering losses because of their consequences. Healthcare fraud, including health insurance branch fraud, has a remarkably negative impact on all parties involved in each case. Combating fraudulent practices involves both the need for internal changes within such companies and the importance of understanding the problem at the level of their customers in order to counteract it effectively.
Fraud in the Health Insurance Field
Undoubtedly, this type of fraud, as well as any other type of fraud, falls under the federal level of criminal prosecution and consists of the fact of conning a person or organization in order to obtain a benefit in financial terms. There are several types, many of which are relatively recent. The popularity of this type of illegal activity has grown for many reasons, including the Covid-19 pandemic (Johnson et al., 2021). Particularly significant is the fact that human life and health can suffer as a result of such actions, and it is challenging to detect intent when abusing health care.
Among the most common, such frauds can be divided into four categories according to the potential beneficiaries. The medical establishment is rarely the perpetrator of misconduct, but there are occasional instances of operating without a license or falsifying tests/assigned medications for a benefit (Santoso et al., 2018). An officially registered insurance company can likewise deceive clients by providing incomplete or incorrect information or issuing inflated premiums policies.
Fraud by customers themselves or third parties is much more common. Clients may demand refunds for medical services that were not provided, use someone else’s insurance information for their benefit, or even falsify documents and signatures. Third parties, on the other hand, most often target potential patients and, under the guise of a fake insurance company, for example, may extort money from the public without providing services (Santoso et al., 2018). Especially susceptible to this type of fraud is the most unprotected layer of the population – the elderly citizens of the state.
Major Initiatives for Building Organizational Resilience to Risk
With the increased demand for health insurance due to the pandemic, the number of abuses has increased as well. For this reason, organizations such as Health Blue and others urgently need to increase fraud protection to avoid financial problems. There are several significant initiatives, some of which are already being actively implemented by healthcare companies to avoid or mitigate fraud. These include several internal changes within organizations, updating, and tightening guidelines, and internal employee action plans.
Since most fraud attempts relate to trying to get money by providing false, someone else’s, or fabricated documents by corrupted medical staff, it is essential to remember to be thorough with checks. Today, it is possible to use online resources for cross-checking and checking the availability of documents in the appropriate databases (Johnson et al., 2021; Moşteanu & DBAAUM, 2020). In case of questionable transactions or mismatched information, the employee should take control of the case and follow it closely.
Stricter checks are needed when assessing the legitimacy of medical expenses for which health insurance is used. When instructing and providing technical assistance after the insurance is processed, professionals should additionally alert the client to the importance of communicating with his or her insurance carrier (Moşteanu & DBAAUM, 2020). If there is any doubt or uncertainty, the client may contact the organization to clarify the legality and correctness of the purpose for which the health policy will be used. The support agent should likewise instruct clients in detail about the importance of their legal security. In the event that a client becomes a victim of third-party fraud without consulting his or her insurance provider, losses will be incurred by all. Further legal consequences can be rather unpleasant for everyone involved.
An equally important initiative is the development and implementation of the most unified software product with a shared database and the ability to verify the validity of medical records and related health insurance costs. To avoid possible abuse by system administrators or hackers, the idea of introducing a self-learning neural network, a vague artificial intelligence to control such a system, exists (Johnson et al., 2021). Similar developments are underway in the software industry, but there is no absolutely universal and federally accepted system at the moment.
Furthermore, a provision should be added to the list of recommendations to ensure that health insurance only pays for legally justified services and medications. Such a proposal should help with improving the efficiency of the health insurance industry and increasing safety in the industry (Santoso et al., 2018). In some cases, such a statutorily certified provision could help companies avoid the additional legal costs of lawsuits, which in some cases are initiated by fraudsters to get even more money from the insurer.
Factors, Management, and Barriers to the Organizational Effectiveness
A number of factors that determine the effectiveness of an organization’s actions are universal. In the case of health insurance companies, the main criteria are competent management and competitiveness, logical organizational structure, teamwork, and flexibility to potential changes (Kapadiya et al., 2022). Despite the distinction between these criteria, they are all tightly interconnected and dependent on one another. With the proper management and timely response to negative or positive changes in the company’s operations, its competitiveness and liquidity grow, allowing it to have a margin of safety in case of fraud.
When there is severe turbulence in the company, the goal of critical management is to avoid cyclical losses. In this case, the current problem for health insurance organizations is that fraud and significant losses can raise the monthly payment on customers’ policies, causing dissatisfaction, customer churn, or lawsuits (Kapadiya et al., 2022). For an organization, such a trap can cause bankruptcy, and the degree of efficiency is correspondingly determined by the company’s ability to avoid this situation.
Barriers to effectiveness primarily disrupt organizational productivity’s three basic qualities: communication, action, and time. Accordingly, when there is incomplete, incomplete, or insufficient communication between employees at any level among themselves or with customers and others, a dangerous barrier to the development and normal functioning of the company is created. Action or its absence is of no less importance and suggests that a timely but wrong action may cause as much or more harm as its absence. Time combines all of the above qualities and is an irreplaceable resource – an untimely decision or action will have a remarkably negative impact on the health insurer.
The Mission of the Organization
The mission is a brief statement formulated by the organization, revealing the main interests, goals, and methods of achieving them. Undoubtedly, the main goal of any for-profit company is to earn money or to gain financial benefits, but in the case of the mission, this point usually is not taken into account (Moşteanu & DBAAUM, 2020). A few sentences define the primary goal of a company’s activities in its field. For example, many private and public firms have similar goals in health insurance. These organizations and Health Blue is one of them, prioritize providing all citizens with financially affordable, high-quality, professional coverage for medical expenses.
In addition, the mission statement often states a commitment to growing to provide even better services to their clients. Furthermore, willingness to fight any challenges that might bring about change is welcome (Kapadiya et al., 2022). These changes imply not only and not so much the fight against fraud in the field but the flexibility and instability of the entire healthcare industry (Sun et al., 2020). Constant changes in laws, regulations, and rules require maximum focus by the health insurance company to function successfully.
Impact of the Organizational Actions and Strategy
Every firm has a particular impact on everything around it, primarily on society. If the many different industries cannot always boast of their actions or effects on society members, health care is one of the most connected to people. That said, it is not unreasonable to note that the importance of health care is one of the highest and is appreciated by every member of society (Kapadiya et al., 2022). Health insurance, as part of this sphere, is an indispensable factor of influence at the national level.
Despite the dissatisfaction of many citizens with specific organizations or the cost and set of their services, no one today can deny the convenience and profitability of the very principle of insurance for all the fragility of human life and health. Optimization of the services provided takes place constantly in a competitive environment, as in many other types of business. In any case, every member of society can be assured that if they are dissatisfied with one organization, they have the opportunity to choose for themselves an alternative, of which there are plenty on the market.
The popularity and importance of the field are again underscored by the abundance of fraud attempts and the percentage of people who fall for it – people tend to be serious and distracted when it comes to their health. For this reason, health insurance organizations must actively educate the masses on protecting themselves from potential healthcare fraud. Companies like Health Blue always face fraud attempts and can educate their clients to counter them.
Strategies, on the other hand, define a vision for their existence and a direction for movement in the vector of the organization’s development. A long-term development plan, or strategy, is drawn up on the raw data, and its impact is felt for the most part exclusively within the company (Moşteanu & DBAAUM, 2020). However, the basic principle of strategies in health insurance firms comes down to optimizing and simplifying their actions, planning against fraud, and developing maximum efficiency of work – a combination of a high return on investment with accelerating processes and improving the quality of services provided.
Considering the Risks
Understanding all risks is essential to the survival of any company in any line of business. There are different threats to health insurance and the fundamental risks associated with financial activities. In addition to a variety of levels and types of fraud, an organization can face the consequences of customer dissatisfaction (Sun et al., 2020). Ongoing disputes and lawsuits are far more common in insurance than in some other industries.
Conclusion
Despite the complexity of the functioning of organizations related to insurance, today, there are many successful examples. Providing the public with the opportunity to cover the costs of treatment, which are often sudden and hard on the individual budget, is extremely important. Even with the current fraud activity level, health insurance companies can significantly contribute to public awareness and safety in addition to resisting. Moreover, most modern companies have long been practicing detailed advice to customers in the execution process of the contract. Furthermore, the ongoing helpdesk assistance to suppress any attempts at abuse against their customers is never refused.
References
Johnson, M., Albizri, A., & Harfouche, A. (2021). Responsible artificial intelligence in healthcare: Predicting and preventing insurance claim denials for economic and social wellbeing. Information Systems Frontiers: A Journal of Research and Innovation.
Kapadiya, K., Patel, U., Gupta, R., Alshehri, M. D., Tanwar, S., Sharma, G., & Bokoro, P. N. (2022). Blockchain and AI-empowered healthcare insurance fraud detection: An analysis, architecture, and future prospects. IEEE Access: Practical Innovations, Open Solutions, 10, 79606–79627.
Moşteanu, N. R., & Department of Business Administration American University of Malta, Malta. (2020). Challenges for organizational structure and design as a result of digitalization and cybersecurity. The Business & Management Review, 11(1), 278-286.
Santoso, B., Hendrartini, J., Djoko Rianto, B. U., & Trisnantoro, L. (2018). System for detection of national healthcare insurance fraud based on computer application. Public Health of Indonesia, 4(2), 46–56.
Sun, C., Li, Q., Li, H., Shi, Y., Zhang, S., & Guo, W. (2019). Patient cluster divergence based healthcare insurance fraudster detection. IEEE Access: Practical Innovations, Open Solutions, 7, 14162–14170.