Fraud detection integral to the success of government healthcare initiatives


Healthcare schemes rolled out by the government have faced unique implementation challenges. Common among them is the challenge of detecting and managing fraud, to ensure that benefits reach the right people optimally.

Detection and management of fraud is critical for the success of any government healthcare initiative. 

Since 1999, about 10 healthcare schemes have been rolled out by the government. These initiatives have been at central and state levels and have faced unique implementation challenges. Common among them is the challenge of detecting and managing fraud, to ensure that benefits reach the right people optimally. 

The problem of fraud in India is multi-fold. Large-scale initiatives, comprising beneficiaries and stakeholders in crores, are vulnerable to fraud by the virtue of being package-based incentives. 

To combat this, it becomes imperious to have strong fraud detection measures embedded into the system in advance. However, altering the approach to value-based care delivery might be a more effective and permanent solution. 

False statement of eligibility, identity theft, conspiracy with service providers to submit false claims are all likely frauds that mass healthcare initiatives should anticipate and build contingency for. With a change in the system towards a value-based approach, various processes can be streamlined. Efforts can be made to use the benefit packages such that they are disincentivised towards abuse or waste. 

Leveraging technology to promote transparency and accountability

Technology can be leveraged towards building a robust value-based care delivery system. This would reduce manual interventions and effectively integrate multiple systems for a single window. It would also ensure transparency, accountability and responsibility, enabling the programs to work independently while still being prepared to detect and manage fraud.

Countries around the world face the challenge of fraud. With the effective use of technology, the entire infrastructure can be digitized, such that the loopholes that enable fraud can be plugged. 

In India, digitization and the use of technology is at a relatively low scale. While developed countries such as US, UK, Australia, and many others have electronic medical records at the core of their healthcare infrastructure, India still struggles with a largely paper-based system impacting both public and private insurers.

By its very nature, a paper-based system is vulnerable to fraud and abuse. A digital system, on the other hand, would promote visibility, immediate access to information and easy verifiability. 

Advanced technologies offering greater potential to secure against fraud

Advanced and open source technologies such as artificial intelligence, machine learning, advanced analytics, big data and blockchain offer an even greater potential towards securing digital transactions, safeguarding data against cybercriminals, reducing counterfeiting and identifying fraud through real-time monitoring.

Open source programming languages will further statistical analysis and enable susceptible healthcare providers, identifying early warning indicators and improving selection of risks for underwriting. 

While the adoption of advanced analytics by the private and the public sector is still relatively low, leveraging fraud, waste and abuse (FWA) analytics can help reduce the proportion of losses.

Players in health insurance are also only beginning to expand at a rapid rate and can utilise analytics towards nipping FWA in the bud and establishing best practices early on.

Visualisation techniques in common use today can make hidden trends and patterns visible to investigators and decision makers in organisations responsible for the finances. 

Additionally, statistical and probabilistic algorithms can help identify fraud not just on an individual claims level but also at an aggregate level to expose instances of organised fraud. 

The concurrent rise of technology and health insurance gives India the opportunity to leapfrog to stop fraudulent claims proactively, as opposed to the developed countries that had to resort to post-payment recovery because of the unavailability of such technologies in the hey-days of health insurance there.

Public private integration essential to create a fraud-proof infrastructure

India’s healthcare and health insurance industry has been fairly vulnerable to abuse. The fight against it, though, cannot be won with a one-size-fits-all approach. Traditional fraud detection and management strategies must be tailored as per the environmental and geographical nuances, and emphasis needs to be on delivery value. 

India needs an integrated effort to transform the existing system in this direction, such that the true potential of the government schemes can be reached. 

A growing number of private players in the domain of technology are dedicating resources towards building high-end capabilities that could map beneficiaries, track insurers and healthcare providers, in their own right.

However, on a country-wide scale, the system can be made comprehensive only when these capabilities of the private sector adjoin forces with the efforts of the various public initiatives. 

With the help of an integrated public and private participation, reinforced with real-time information, made available by streamlined processes, claims can be administered and checks on quality of the service patients receive can be bettered. 

While it is important that the government undertake initiatives to bridge the healthcare gaps in the country, it is equally important that all measures are taken in collaboration with those who are already developing capabilities of detecting and preventing fraud, so that the common man of India receives the care he deserves. 


The above article appeared in ETHealthworld.