The occurrence of fraud in health plans is a frequent and worrying problem, which negatively impacts the finances of operators, and may even harm the quality of care for beneficiaries. Given this context, health insurance company managers must understand how human resources (HRs) play a crucial role in preventing and combating fraud in health plans, making them great allies.
Recently, FenaSaúde also highlighted the importance of HR in combating fraud, issuing the following warning: “While companies seek and discuss more and more frequently the conscious management of people, costs and resources, fraud is a problem for the entire system of health. Especially in the case of collective corporate health plans – which currently represent more than 80% of the Brazilian market. Given this scenario, the human resources area is essential in providing information, alerting and, above all, raising awareness among its employees about the good use of plans, the risks and impacts that fraud has on one of the most desired beneficiaries. ”
During CONARH Saúde 2023, the executive director of FenaSaúde, Vera Valente, participated in a panel on the topic “How to Better Invest in Health”, accompanied by José Ricardo Amaro, HR director of GRSA COMPASS, and Valquíria Cunha da Rocha, director -general of Telefónica, moderated by Claudio Tafla, president of the Alliance for Population Health – ASAP.
At the event, the executive director presented the Health Without Fraud Campaign, www.saudesemfraude.
“Companies and human resources departments are fundamental in this awareness work. People need to understand that fraud has an impact and turns against themselves, increasing the cost of plans, putting the offer of this type of benefit and even their own employment at risk”, explained the executive director of the National Federation of Supplementary Health ( FenaSaúde), Vera Valente, during a debate at CONARH Saúde 2023, held on May 31st.
In this article, we will discuss the importance of HR in this process and how they can contribute to identifying, preventing and dealing with fraud.
Fraud identification
One of the main functions of HR is to identify possible fraud in the processes and transactions carried out by health plan operators. To achieve this, it is necessary to establish an organizational culture that values ethics and transparency, encouraging employees to report any suspicion of fraud. Additionally, HRs can implement internal control and monitoring mechanisms to identify suspicious patterns in financial transactions and in the records of beneficiaries and service providers. A tip: get to know the medical bill audit system used by the largest Brazilian healthcare providers.
Fraud prevention
Fraud prevention is a fundamental strategy to minimize negative impacts on health plans. HRs play a crucial role in implementing policies and practices that aim to mitigate fraud risks. This involves adopting preventive measures, such as periodic review of internal processes, adequate verification of information provided by beneficiaries and service providers, carrying out internal audits and the promotion of training to raise awareness among employees about the importance of acting ethically and complying with rules and regulations.
Collaboration with other sectors
HR must also work in an integrated manner with other sectors of health plan operators to strengthen prevention and combat against fraud. Collaboration with the legal area, for example, is essential to ensure compliance with applicable laws and regulations and to support the investigation of fraud cases. Furthermore, integration with the information technology area can allow the use of advanced tools and systems to fraud monitoring and detection, such as data analysis and artificial intelligence.
Investigating and combating fraud
Employee awareness and training
Employee awareness and training are key elements in preventing and combating fraud in health plans. HRs can play a key role in creating comprehensive training programs that address ethical issues, standards of conduct, anti-fraud policies and consequences for those who engage in fraudulent practices. These programs must be ongoing and promote a culture of integrity and compliance.
How Brazil's largest healthcare providers protect themselves against fraud
Human resources play a strategic and essential role in preventing and combating fraud in health plans. Through identification, prevention, collaboration, investigation and awareness, HR can significantly contribute to reducing fraud risks and ensuring a ethical and transparent management in health plans.Now we'll tell you what the largest healthcare providers also do: they invest in the structuring and total transparency of processes, reduction or even almost elimination of disallowances, automatic recording of all steps of a medical bill audit and much more.
To protect themselves from fraud, the largest Brazilian health plan operators invest in technology. They use the Medical Bill Audit most awarded in the country, the SAUDI. With this modular and fully customizable software, they ensure the integrity of all processes, always following market developments and updates to sector regulations.
It is important that health plan operators value and invest in human resources and also in technologic solutions as pillars in preventing and combating fraud, aiming to guarantee the quality of services and financial integrity.
