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Claims Investigation

Insurance fraud is described as an intentional act - of deceiving, concealing, or misrepresenting information that results in healthcare benefits being paid illegitimately, to an individual or a group. The purpose of investigation is to ascertain the authenticity and genuineness of referred suspicious claims basis the evidences collected thereby mitigating fraudulent activities and intent. Our team of investigators includes medicos, paramedics, legal advisors, panel of honorary medical experts & experts from insurance industry.

Why do we investigate insurance claims?
  • To control the claim ratio (ICR – Incurred Claim Ratio)
  • To understand the behavior of hospitals in Region
  • To identify the adverse claims behavior
  • To identify the nexus if any, between any hospital and agent / client or other intermediary
  • To confirm hospital eligibility as per the policy conditions
  • To control prolonged hospitalizations and over-billing / over stay
  • To identify good hospital who are willing to work on reasonable SOC under TPA network of hospitals
  • To synchronize and educate hospitals / patients to utilize the policy in proper manner
  • To find frauds and misrepresentations
  • To find pre-existing ailments, OPD converted into IPD
  • To find authenticity of claim submitted
  • To find the existence of insured, any impersonation done
Average turn-around-time per investigation is 14 working days. Average hit rate is 20% month on month. We offers claim investigation services across India. Email us on investigations.phm@paramount.healthcare for more information.
 
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