The DoH Disciplines Healthcare Facilities Over Health Insurance Violations

The Department of Health – Abu Dhabi (DoH), the regulator of the healthcare sector in the Emirate of Abu Dhabi, has taken a number of legal disciplinary measures against healthcare facilities and health professionals for violating insurance laws and regulations.

Examples of violations include the manipulation of financial claims data through the addition of false information— with the intent to incorporate the provided healthcare service to the health insurance umbrella. Other examples of violations also include the advertising healthcare services targeting Thiqa cardholders without approval from the DoH, as well as obtaining greater insurance compensation by requesting reimbursement for additional services that were not actually provided to patients.

Legal measures taken by the DoH involve; excluding the infringing services from the Thiqa insurance scheme; cancelling claims submitted by the violating health facilities; imposing fines for every claim within the infringing service; and the recovery of previously paid unjustified claims.

The Department of Health – Abu Dhabi confirmed that it does not tolerate the actions taken by anyone seeking to mislead or exploit the system; and that in the event of a violation, the DoH would take the necessary strict disciplinary measures against offenders by turning them over to the legal authorities. The Department of Health – Abu Dhabi, urged all residents of the Emirate to download and use its application in order to track all financial claims submitted by healthcare facilities and monitor their insurance profile, to help alerting users to any irregularities within their individual claims.

H.E. Sheikh Abdulla Bin Mohamed Al Hamed, Chairman of the Department of Health – Abu Dhabi, stated: "Based on our commitment to providing quality healthcare services to all residents of the Emirate of Abu Dhabi, we have taken action against entities and individuals who violate health insurance laws, in addition to further developing and organizing access to healthcare— while improving quality and cost-efficiency. The DoH is working to achieve its vision for ‘a healthier Abu Dhabi’ by ensuring that healthcare facilities and employees comply with all regulations, and that they contribute to the sector’s sustainability through the proper use of health insurance benefits."

H.E. added: “The DoH is working alongside all public and private healthcare facilities across the Emirate, in order to provide the best services possible to patients— by ensuring that these services are in accordance with the highest international standards, as well as the regulations set by the Department of Health – Abu Dhabi.”

In a case of insurance fraud that was uncovered, the DoH logged and conducted an investigation which resulted in the discovery of evidence that the offender, a Dentist, had indeed sought and obtained prior approval from the insurance provider for the treatment of a large number of teeth for a single patient, while that patient had only actually required treatment for fewer number. The evidence proved a clear breach of the laws and regulations— through the misrepresentation of the diagnosis and required treatment, with the intent to mislead the insurance provider. Following the investigation, DoH transferred the case file to the legal affairs and recovered all unjustified amounts that were paid.

In another incident of insurance fraud, a healthcare facility applied an insurance claim to cover the cost of a service provided to a Thiqa insurance cardholder. The concerned healthcare facility alongside another facility, had provided incorrect information about the insured individual’s health condition. The patient’s personal information was incorrectly reported on the request form, so that they could be eligible for a surgery, as per the standards enforced by DoH.

Due to this fraudulent behaviour, the medical practitioners’ licenses were banned from providing this type of healthcare service under the health insurance scheme in the future. Similarly, the involved healthcare facilities are now also strictly forbidden from providing these services. All insurance claims that were paid to the two facilities related to this violation, were recovered by the DoH, in addition to enforcing a fine for each violation.

Another case saw a healthcare facility advertise their dental services to Thiqa Insurance cardholders without obtaining the necessary approval from DoH. This resulted in an increased use of Thiqa insurance cards at the healthcare facility, which in turn increased the costs associated with the insurance program. As a penalty, the Department of Health – Abu Dhabi excluded the facility from their Thiqa network and transferred the case file to legal affairs, for the necessary action to be taken. Further, unjustified claims that were paid to the facility were recovered.