Various types of fraud in supplementary healthcare have been growing steadily in Brazil, affecting both healthcare service providers and plan users.

In recent months, more than 100 employees were fired by the CCR Group after an internal investigation found misuse of the health plan reimbursement benefit.

The fraud amounts to a loss of R$ 12 million for the company over five years.

The cases mainly involve beauty and weight loss treatments, RPG and acupuncture, and add up to a loss of R$ 12 million for the company in five years.

“Fraudsters shared the value of unpracticed, overpriced or unnecessary procedures with professionals or fake health clinics,” said the company in a press release.

According to the CCR, the case involves flaws in the process carried out by the health operators that make the reimbursements. It is estimated that fraud increases the cost of health insurance between 5% and 10%, both for companies and employees.

A similar incident occurred at Itaú, with the dismissal of 80 employees last month. According to the bank, there was misconduct by employees in requesting reimbursement for consultations and procedures.

Fraud involves a wide range of harmful practices, which can harm both businesses and customers.

Most common types of fraud in supplementary healthcare

In this article, we will present the most common types of fraud in supplementary health and provide essential tips on how health plan providers can protect themselves. Let's start by analyzing the most common types:

Improper billing

Undue billing, as occurred with CCR and Itaú, is one of the most common problems faced by health plan operators.

In this type of fraud, the healthcare provider charges for services that were not performed or were performed inappropriately, such as medical consultations or exams.

In addition, fraudsters can also use beneficiaries' personal information to create false profiles and charge for services not contracted.

To avoid this type of fraud, healthcare providers can carry out a strict control of charges and exams, leaving a real-time data validation system, with workers trained to identify discrepancies between recorded information and customer needs.

Document Forgery

Document falsification is another very common fraud in supplementary healthcare. Those who practice this type of fraud create falsified documents, such as medical invoices, to simulate real expenses and get paid for services without any type of justification.

Fraudsters can also tamper with original documents, adding extra amounts or procedures to justify charging higher amounts.

To protect against document falsification, operators need to maintain a fraud inspection team constantly working on medical bills, carrying out detailed audits to verify the authenticity of documents and process details.

Fake Service

Another very common scam in supplementary healthcare is fake service. In this scheme, criminals pose as doctors and other authorities, offering fraudulent services to beneficiaries seeking medical care. This type of fraud can be very dangerous, as patients run the risk of not receiving adequate care or being treated by unqualified professionals.

To avoid this type of problem, health plan operators must maintain strict control over the accredited network and constantly monitor the services offered by the network, in order to avoid fraud and minimize risks.

Fake Accredited Networks

In addition to the scams described above, there are many other frauds that can occur in the supplementary healthcare sector. Another example is fake accredited networks, which are created to obtain money from beneficiaries without providing any type of service in return. To avoid this type of problem, health plan operators must maintain a rigorous accreditation verification system, monitoring the integrity and ethical practices of accredited service providers.

Fraudulent Documentation

The use of fraudulent documentation is also a common practice in the supplementary healthcare sector. Documentation is often tampered with to present false information, which can lead to fraudulent payments by the healthcare provider.

To avoid fraud with falsified documentation, health plan operators must keep detailed records of all official documents, with procedures that strengthen data security and information confidentiality.

How to protect your healthcare provider against fraud

Supplementary healthcare is a segment that requires constant monitoring to detect and prevent fraud, because it can affect both service providers and customers.

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.

Another very important and valuable tip is to create actions to raise awareness among users about anti-fraud practices, because in addition to being a form of prevention, it is also a strategy that eliminates the problem at its root.

Request a demo of SAUDI and understand how the system preferred by medical account managers manages to shield Brazil's largest healthcare providers against various types of scams and fraud.