Analysis of Health Insurance Violations in Saudi Arabia - Module 11

This discussion forum post analyzes a current news article concerning fraudulent health insurance claims in Saudi Arabia, specifically focusing on the period from January to September 2018. The assignment highlights the significant increase in complaints against health insurance companies, primarily involving inflated claims by hospitals and private practitioners, unnecessary medical tests, and conflicts between insurance providers and healthcare services. It then examines the Council of Cooperative Health Insurance's (CCHI) response, including a new claims process implemented in October 2018, which mandates claim filing within 45 days, insurer settlement within 45 days, and stricter monitoring of doctors and hospitals. The post also discusses the varying perspectives on these regulations, including the potential benefits of increased ethical practices and patient confidence, alongside concerns about increased healthcare costs. The post concludes by referencing the importance of insurance regulations, drawing on historical examples of government intervention to stabilize insurance markets and protect consumers, emphasizing the necessity of these regulations to prevent fraud and maintain a fair healthcare system.

Discussion Forum
Fraudulent insurance claims
Saudia Arabia

Last 9 Months starting from January to September of the year 2018 has witnessed 18739
complaints against health insurance companies ("Over 18,700 complaints about health insurance
in 9 months", 2019). The complaints mainly indulge the health insurance companies and the
health service providers. The major reasons or issues that have come up in these
accusations are mentioned below ("Insurance firms to sue corrupt hospitals", 2019):
1. Hospitals and Private Practitioners are illegally inflating claims by delaying
treatments. Doctors are joining hands with corrupted health service institutes and
inflating medical treatment bills by extending the release date and keeping cured
patients under observations. All this in return of percentages.
2. Minor Illness are being sent for expensive laboratory tests, where the laboratories
are passing on a commission to the person making such prescription. Sometimes
they are the doctors and sometimes the private hospitals. There has been cases
where there was no need for such medical tests.
3. The fight between the health insurance companies and the health service providers
are creating problems for the patients and their family. The innocents are keeping on
the losing side.
These issues have kept the nation at unrest and has alarmed the health insurance
companies and the Saudi Arabia’s Council of Cooperative Health Insurance. The council has
issued a circular on the 22nd of July 2018 addressing the health insurer, health care provider
and TPAs that a new claim process will come from the month of October 2018 ("KSA Health
Insurance: New Claims Process Becomes Effective In October 2018 - Food, Drugs, Healthcare, Life
Sciences - Saudi Arabia", 2019). The below mentioned are some of the new inclusions:
1. The claim has to be filed within 45 days from the date of entitlement of claim by the
healthcare providers directly.
2. The insurer needs to settle the process within 45 days of receiving the claim.
Rejected claims has to be provided with a list of reason for rejection.
3. In case of rejected claims, the healthcare provider shall review the rejection and
revert back to the insurer within 22 days.
4. The Insurer will again have to review the claim within 22 days of the receipt of
additional submission from the healthcare provided.
Amongst other steps, the Health insurers are creating an institute together. This institute
will monitor the activities of the Doctors and Hospitals. Such monitoring will screen out the
medical ill practitioners. The insurance firms are also preparing a list of some private
hospitals which will be blacklisted, on the basis of the complaints received. These steps will
regularise the claim process and is also expected to arrest the corrupt practices.
Medical Director of a Private hospital, Ali Al-Shanbari, has expressed his views on this issue
of health insurance claim corruption. His views had acceptances as well as rejections. He
detested the fact that all medical houses, private hospitals and doctors are involved in this

malpractice. He added by agreeing to the fact that there are some who are greedy, requests
unnecessary medical bills, longer treatments etc.
The tougher monitoring system being created by the Health Insurance companies will have
both positive and negative results. The positive of it will result in the addition of an Ethical
sense in the industry practice. The Health industry is a section where patients are the ones
who trust their life’s on the Doctors and the Health Care institutions. This trust is getting
breached. The strict monitoring system will help regain confidence of the patients on the
Health Care system. The downside of this system will be Health Care service getting
expensive. Most of Health Care Institutions have profit motives behind the veil of society
wellbeing, which encourages them to undertake fraudulent means on the insurance claims.
Strict monitoring will hamper the profitability directly and result in price hike of services is
not controlled by the government.

References:
KSA Health Insurance: New Claims Process Becomes Effective In October 2018 - Food, Drugs,
Healthcare, Life Sciences - Saudi Arabia. (2019). Retrieved from
http://www.mondaq.com/saudiarabia/x/727858/Healthcare/KSA+Health+Insurance+New+Clai
ms+Process+Becomes+Effective+In+October+2018
Insurance firms to sue corrupt hospitals. (2019). Retrieved from http://www.arabnews.com/saudi-
arabia/news/817231
Over 18,700 complaints about health insurance in 9 months. (2019). Retrieved from
http://saudigazette.com.sa/article/551471