The Hospital That Never Had Empty Beds

01The situation

Occupancy was always full. Many of the patients went home the same evening.

A health insurer saw a handful of network hospitals in one region produce far more claims per policy than comparable hospitals, with short stays and high bills.

02How it worked

1. 01Agents sold policies to groups of people and later steered them to particular hospitals.
2. 02Hospitals admitted patients for conditions treatable on an outpatient basis, or recorded admissions that did not happen.
3. 03Bills were inflated with procedures and consumables not provided.
4. 04Policyholders received a share of the claim or free treatment.
5. 05Documents were prepared to fit policy terms.

03The challenge

Separate legitimate care from fabricated or inflated claims, establish collusion between hospitals, agents and policyholders, and hold up in empanelment and legal decisions.

04Our approach

1. Workstream 01

   Claims analytics

   Hospital, agent and policyholder patterns across the book.

2. Workstream 02

   Medical review

   Clinical assessment of whether admissions were needed.

3. Workstream 03

   Field verification

   Independent visits to hospitals and policyholders.

4. Workstream 04

   Agent and hospital link analysis

   Relationships behind the claims.

05What we found & did

• Fabricated and unnecessary admissions in a large share of flagged claims.
• Bills inflated with services not provided.
• Agents coordinated policies and admissions.
• Other hospitals in the region were clean.

06The impact

07Lessons for your business

The controls that would have stopped this, or caught it sooner:

• Benchmark hospitals by admission rate and stay length.
• Link agents, policies and hospitals in analytics.
• Verify a sample of high-risk claims in the field.
• Watch claims soon after policy inception.