The UK has seen increased consumer interest in private healthcare insurance in recent years as more people become dissatisfied with NHS waiting times and experience increasing restrictions on treatment.
The UK private healthcare market is expected to grow by 2.8% per annum to 2025 according to Persistence Market Research. This growth opportunity is attracting new healthcare insurance entrants to the market. It has been suggested that Amazon could soon target the UK in its efforts to disrupt the healthcare insurance market.
Set against this backdrop, as the healthcare insurance market grows so too does the risk of healthcare insurance fraud, with the weakened UK economy creating incentives for criminals.
Healthcare fraud is committed when a dishonest provider or consumer intentionally submits, or causes someone else to submit, false or misleading information which is used to determine the amount of healthcare benefit payable.
Fraud committed by healthcare providers can include: billing for services not performed; billing for a more expensive service than the one performed; misrepresenting procedures performed to obtain payment for non-covered services; billing each stage of a procedure as if it were a separate procedure; falsifying a patient's diagnosis to justify unnecessary treatment; accepting monies ‘kickbacks’ for patient referrals; waiving patient co-pays or deductibles and over-billing the insurer; billing a patient more than the co-pay amount for services that were prepaid or already paid in full by the insurer; false or unnecessary issue of prescription drugs.
The NHS is also being exploited for financial gain with fraud costing a conservative estimate of £1.25 billion per annum according to the NHS Counter Fraud Authority. It is estimated that prescription and entitlement fraud alone, which is largely attributed to patients and the general public, costs the NHS £217 million each year. Typical frauds impacting the NHS include false claims and prescription fraud, payment diversion fraud, procurement fraud, professional misrepresentation fraud and time sheet fraud.
