Year-End Trends Reveal Infectious Diseases, Mid – Ticket size claims and Misrepresentation in Reimbursement claims as fraud hotspots,  Says Medi Assist

Medi Assist- BGG analysis reveals highest fraud propensity in ₹50,000–₹2.5 lakh claims, infectious disease categories, and impersonation-led hospitalizations

16 December 2025: India’s health insurance sector is witnessing a dramatic shift in how fraud is being committed. According to Medi Assist and the Boston Consulting Group’s report- ‘Combating Fraud, Waste and Abuse in India’s Health Insurance Ecosystem,’ fraudsters are shifting from high-value claims to mid-ticket claims. Findings show that medical categories, which are harder to verify such as inflated treatments, staged hospitalizations and ambiguous diagnostic codes are shaping the next phase of fraud risk for the industry. These trends are appearing across hospitals and clinics nationwide as millions of claims are processed every year.

To combat this, Medi Assist has deployed MAven Guard, an AI-powered Fraud, Waste and Abuse detection engine. By integrating this technology across cashless and reimbursement workflows, the company reports saving over ₹400 crore in FY 25, improving fraud detection rates by 2X–3X

Mid-ticket claims show highest fraud concentration

Exhibit 1: Fraud Risk Trends by Claim Value Over the Years

• Fraud is most common in the ₹50,000 to ₹2.5 lakh claim range, which offers meaningful payouts but usually faces only moderate checks. This segment often sees inflated procedure codes, exaggerated treatments, and staged hospitalisations.
• In contrast, claims above ₹2.5 lakh carry much lower fraud risk because they go through stricter pre-authorisation and detailed audits.
• Smaller claims below ₹50,000 are also seeing rising fraud, mainly through inflated consumables and minor charges that are harder to track due to limited documentation.

Fake hospitalizations and impersonation as critical threats

Exhibit 2: Fraud Risk Relative Propensities across scenarios in different care settings

• Among inpatient claims, the highest fraud risk comes from misrepresentation and fake documents.
• Impersonation and staged admissions also stand as distinct trends. This includes using someone else’s identity for reimbursement, creating fake admission or discharge papers, and staging hospital stays with little or no treatment.

Infectious diseases carry the highest fraud risk

Exhibit 2: Fraud Risk Across Different ICD Groups

• Infectious Diseases show the highest risk because symptoms can be vague, claim volumes are high, and cases depend heavily on diagnostic reports.
• Digestive, respiratory, skin-related, and injury cases also carry moderately high risk, as their symptoms can be subjective and easier to manipulate.
• In contrast, surgical or procedure-heavy categories such as circulatory, genitourinary, pregnancy and childbirth, eye disorders, and neoplasms show much lower fraud risk because they require stricter documentation and specialist oversight.

MAven Guard addresses these challenges by deploying advanced analytics, anomaly detection, and real-time data verification to identify suspicious behaviour much earlier in the claim cycle. Our Prevention–Detection–Deterrence framework strengthens the integrity of every claim by reducing unnecessary admissions, automating validation checks, and ensuring consistent standards for providers, members, and intermediaries.

Medi Assist’s AI-powered fraud screening engine. MAven Guard evaluates incoming claims against risk scores, clinical benchmarks, hospital behaviour patterns, and historical anomalies helping detect mismatches, abnormal billing patterns, inflated consumables, and suspicious admission profiles in real time. By integrating MAven Guard across cashless and reimbursement workflows, we are tightening early-stage detection and reducing leakages before they escalate.

With continued investments in interoperable platforms aligned with the Ayushman Bharat Digital Mission and National Health Claims Exchange, governed GenAI models, and standardized clinical protocols, we are systematically closing the loopholes that fraudsters attempt to exploit. Ultimately, our focus is on building trust, protecting policyholders, and advancing a future-ready, fraud-resilient ‘Insurance for All’ ecosystem.