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Dissertation (Synopsis)

The document discusses a study on blacklisting network and non-network hospitals found to commit insurance fraud. The study aims to analyze fraud incidents, understand average claim sizes, and identify unwarranted losses to reduce costs. Secondary data on suspected fraudulent hospitals will be collected from an insurance company and analyzed using Microsoft Excel to minimize fraud and reduce claim sizes.

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Samiksha
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32 views2 pages

Dissertation (Synopsis)

The document discusses a study on blacklisting network and non-network hospitals found to commit insurance fraud. The study aims to analyze fraud incidents, understand average claim sizes, and identify unwarranted losses to reduce costs. Secondary data on suspected fraudulent hospitals will be collected from an insurance company and analyzed using Microsoft Excel to minimize fraud and reduce claim sizes.

Uploaded by

Samiksha
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as DOCX, PDF, TXT or read online on Scribd
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SYNOPSIS

(Submitted by - Dr. Samiksha Arun Rushiya, MBA-HM Batch - 26)


 TITLE -
A STUDY ON BLACKLISTING OF NETWORK & NON-NETWORK HOSPITALS.

 INTRODUCTION -
This world is full of uncertainties and threats. The unpredictability of unpleasant things happening to
people's lives, well-being, resources, and property is just one example of the different types of risks
that can exist. In order to protect the interests against catastrophe and vulnerability, the Insurance
Industry has evolved to cover the loss and uncertainty. It might be presented as a tool for society to
lessen or get rid of the threat to people's lives and property.
In addition to protecting people and businesses from numerous potential risks, insurance makes a
considerable financial contribution to the country's overall development by promoting secure
contacts. Millions of people are employed by the Insurance industry, which is particularly important
in nations like India where employment and savings are crucial. Due to all these benefits, insurance
fraud unfortunately has a high likelihood. About 45,000 crores worth of insurance fraud was
committed in India in 2019. In general, Fraudulent health insurance claims can range from 15% to
35%, and overall it results, insurance firms to often lose 10% to 15% of their revenue.
One of the biggest markets in the world for insurance companies is India. However, it should be
understood that due to an abnormally high prevalence of fraud, doing business in the health
insurance sector in India comes with many risks.

 RESEARCH QUESTION -
WHAT IS THE PROCESS OF IDENTIFICATION AND IMPACT OF BLACKLISTING THE HOSPITALS AT
HEALTH INSURANCE INDUSTRY LEVEL?

 OBJECTIVES -
 To understand the Average Claim Size of both Cashless & Reimbursements
 To study the Fraud-Abuse claim incidences in Hospitals Pan India
 To analyze Unwarranted Losses further leading to overall Cost Reduction

 HYPOTHESIS -
Prevention in claims from blacklisted hospitals will result in lower Average Claim Size.

 RESEARCH METHODOLOGY -
 STUDY DESIGN - Correlational Quantitative Study
 SETTING - ADITYA BIRLA HEALTH INSURANCE
 STUDY POPULATION -
 INCLUSION CRITERIA - Suspected Fraud Hospitals
 EXCLUSION CRITERIA - Non- Suspected Hospitals
 STUDY TOOL - Secondary Data

 DURATION OF STUDY - 3 Months (22nd Feb 2023 – 21st May 2023)


 SAMPLE SIZE - Master data consists of 55,000 Hospitals, out of which 2916 Hospitals were
identified as suspected Hospitals.
Conclusions are made on basis of suspected hospitals.
 SAMPLING TECHNIQUE - Purposive Non- Probability Sampling
 DATA COLLECTION PROCEDURE -
A group of insurers came together to tackle hospital fraud. Each insurer shared a list of excluded
hospitals for this purpose. The data was collected using a system portal, and a comprehensive list of
fraudulent hospitals was compiled.

Next, the collected data will undergo multistage analysis. The compiled data will be categorized into
different themes, which will be entered into Microsoft Excel for further analysis. The resulting tables
and graphs will provide a summary of the data. Finally, conclusions will be drawn based on the
themes that emerged from the data analysis.

 OPERATIONAL DEFINITIONS -
1. ACS - Average Claim Size is the total amount paid by ABHI divided by the number of claims
settled for that particular month.
2. BLACKLISTED HOSPITALS - A Blacklisted Hospital is one where the insurer does not provide
cashless or any reimbursement facility.

 DATA ANALYSIS PLAN -


MICROSOFT EXCEL (VERSION 2016):
Along with the rest of Microsoft's Office 2016 Productivity Suite, it is the entry into the excel series
of spreadsheet software, MICROSOFT EXCEL has some of the newly added features in this version –
Histograms (to visualize frequency in data), Pareto charts (showing data trends), and Power pivot,
which allows for the import of higher levels of data and comes with its own language.
The compiled data will be checked for completeness and correctness and data will be entered in
MICROSOFT EXCEL for further analysis.

 ETHICAL CONSIDERATIONS -
Confidentiality of the data to be maintained throughout the study, as the data provided by
organization is encrypted in special codes, so it can’t be linked to other data by anyone else.

 IMPLICATIONS OF RESEARCH -
The study will be impacting the industry by minimizing the fraud & abuse through suspected/ fraud
hospitals. This will result in reducing the cost paid per claim (Average Claim Size) which used to get
paid to those hospitals making it a genuine claim.

 REFERENCES -

Chandra Das, V. (2022, November 14). Health care frauds in India - Causes and Preventive measures.
Paytm
https://paytminsurance.co.in/health-insurance/articles/health-care-fraud-in-india-causes-and-
preventive-measures/

Sinha, S. (2017, July 06). How insurance firms are with fraud claims. The Economic Times
https://economictimes.indiatimes.com/news/economy/finance/how-insurance-firms-are-dealing-
with-fraud-claims/articleshow/59448276.cms

Patil, K., & Abhyankar, M. (2019, March) A study of fraud investigation in fraudulent insurance claim.
ResearchGate
https://www.researchgate.net/publication/
339739901_A_STUDY_OF_FRAUD_INVESTIGATION_IN_FRAUDULENT_INSURANCE_CLAIM

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