The Saudi Insurance Authority (IA) is monitoring health insurance fraud indicators to develop the necessary legislative measures to curb such crime, in cooperation with criminal investigation agencies.
The IA said that it had recently proposed a draft insurance regulation, the provisions of which include coordination with the relevant authorities to detect and monitor fraud cases, in addition to specific penalties for fraud in the insurance sector, reported the state-owned media organisation Al-Arabiya.
Saudi Arabia's health insurance sector generated a revenue of around SAR40.7bn ($10.9bn) in 2024, representing 61.4% of the industry’s total insurance revenue. At the same time, concerns about insurance fraud in healthcare are emerging.
The number of companies providing healthcare insurance services in Saudi Arabia reached 23 by the end of last year. The health insurance branch recorded a loss rate of 83%, with claims amounting to SAR33bn.
The IA has recently identified patterns of fraud, including the misuse of health insurance by uninsured individuals and the filing of bogus claims in which no services were provided. It has also identified misuse of claim coding by some healthcare providers, as well as instances of manipulation, such as unjustified hospitalisation or the dispensing of medications inappropriate for patients’ medical conditions.
These efforts are helped by digitalisation. In 2023, the Council of Health Insurance (CHI) launched Nphies (National Platform for Health Information Exchange Services), which allows access to a comprehensive database of health insurance claims via a direct link between health insurers and healthcare providers. Among its functions, NPHIES analyses health insurance transactions in real time, detecting suspicious billing patterns, anomalies, and red flags before claim approval.