Case Background

Employee with the intention to gain undue amount in form of medical reimbursements raised forged documents and fake lab reports. The issue was brought to the notice of fraud & risk control team and it was investigated against the alleged customer.

Investigation Summary

A preliminary investigation revealed that the medical documents, pathology reports, Doctor’s prescription were fake. The documents submitted appeared to be forged with Doctor’s signatures, edited lab reports to showcase diagnosis and fake medical bills. It was startling to note that the documents submitted to NBHI and Paramount were in collusion with Third-Party.

Hence, post document’s review, the investigation team conducted on ground investigation and met the employee who had raised fraudulent claim. It was further revealed that intentional greed and remissness on the part of an employee contributed to such a misconduct. The intention proven was to gain undue amount by the virtue of medical claim reimbursement. During verification, investigation team could also trace the editable copy of the certificates comprising of: handwritten medical bills, Doctor’s prescription, medical reports and diagnosis with over-written dates to match the treatment date, fake pathology reports with Doctor’s signature passed in the document, manually filled discharge summary with Doctor’s signature in patient’s handwriting and copied signature of Doctor. The alleged in the investigation process had confessed the modus operandi how a third-party with the help of accessing documents from alleged arranged the fake documents

The Investigation revealed that the doctor whose signature was forged in all medical documents confessed to have never treated the alleged and confirmed to have not signing the documents. The hospital was not in NBHI’s provider’s list. Stolen pathology reports were used to align with the treatment showcased. Genuine doctors’ forged signature was used in hospital stamped letter heads for creating discharge paper and medical prescriptions. The alleged cum employee in the said investigation never had any treatment taken and the same was confessed during investigation. The Third Party with the help of employee’s personal documents; PAN Card, Aadhar, employee ID card sourced the forged medical documents and fake bills and reports.

Further investigation revealed another kind of fraud, which was taking place in the hospital. The hospital was found to be infamous for colluding in raising false claims and keep changing the hospital name. They facilitated the Third-party in procuring forge documents, lab reports and fake doctor’s details.

Action taken

Getting all the facts of the cases with proper evidences the team represented this case in front of the concerned internal committee. Post discussions and seeing the evidences the committee decided to terminate employee involved in this matter.

Process improvement

Certain preventive measures were also recommended by the committee and implemented with immediate effect –

· The employee was terminated with immediate effect.

· Non- provider’s list was revised.

· Stringent verification process in validating documents submitted for reimbursement by NBHI’s TPA as per company’s protocol prior disbursement of claim amount