Dr Prabhat Krishna
Bengaluru
Summary
Strategic Insurance & Healthcare Risk Leader with 14 years of experience in health claims, fraud investigation, and risk management. Expertise in building centralized investigation units and implementing analytics-driven fraud detection systems. Proven ability to lead large teams and optimize operational processes. Recognized for developing effective solutions that drive significant fraud savings and enhance organizational efficiency.
Overview
16
16
years of professional experience
Work History
Vice President - Head, Risk & Audit (Fraud Investigation Unit)
Vidal Health Insurance TPA
Bengaluru
11.2024 - Current
- Developed centralized investigation team of 58 dedicated and 20 shared resources to enhance fraud detection capabilities
- Led PAN India fraud investigation across health claims portfolio
- Introduced case differentiation model: Waiver / Field Visit / Desktop Review / AVR-based investigation
- Implemented OTP-based verification for small-ticket cases to strengthen security measures
- Introduced mobile investigation app → 2x productivity increase & 40% TAT reduction
- Real-time field reporting system with structured medical review
- Designed diagnosis-based customized questionnaires & checklists
- Built hospital trend-based audit, flagging & risk categorization framework
- Risk classification model for corporate & hospital segments
- Deployed dedicated provider-portal monitoring team
- Oversight of hospital infra, registration & tariff compliance
- Coordinated vendor and legal recovery efforts for proven fraud cases to recover losses and deter future incidents
- Frequent hospital audits to control inflation & tariff gaps
- Medico-led pre-auth scrutiny for flagged hospitals
- Directed strategic initiatives to enhance health insurance service delivery.
- Collaborated with cross-functional teams to improve operational efficiency and client satisfaction.
- Oversaw compliance with regulatory requirements and industry standards in health insurance operations.
- Developed and implemented training programs for staff to ensure quality service standards.
- Managed relationships with key stakeholders, including providers and clients, to foster partnerships.
- Led performance evaluations to assess team effectiveness and identify improvement areas.
- Championed technology integration to streamline processes within the health insurance framework.
- Created effective communication strategies between management team members and employees at all levels of the organization.
- Implemented process improvement procedures that resulted in cost savings across the board.
- Negotiated contracts with vendors for services, products and supplies.
- Established performance standards for staff members in order to drive productivity levels up.
- Analyzed market trends to identify opportunities for growth within existing markets or new ones.
- Designed incentive programs that motivated staff members while ensuring profitability targets were met.
- Ensured compliance with applicable laws and regulations related to operations activities.
- Reported to executive leadership on performance metrics, challenges, and strategic opportunities.
- Managed annual budgeting process, including forecasting and financial analysis to optimize resources.
- Guided change management initiatives to ensure smooth adoption of new business practices.
- Negotiated high-value contracts with suppliers and clients to improve cost-effectiveness.
- Developed and implemented strategic business plans to drive growth and profitability.
- Coordinated with IT department to implement new technologies and systems enhancements.
- Monitored compliance with industry regulations and company policies to mitigate risk.
- Directed market research and analysis to identify trends and inform business decisions.
- Oversaw technological improvements, successfully reducing waste and eliminating business bottlenecks.
AVP - Special Investigation Unit
TATA AIG GIC Ltd
02.2022 - 11.2024
- Saved ₹160 Crore via fraud investigation
- Developed analytical trigger-score model → 30% TAT improvement, 15% HIT rate increase
- Filed approximately 100 police complaints against fraudsters to support legal actions and recoveries
- Managed team of 17 medicos and 6 analytics/technical experts to enhance investigation processes
- Directed comprehensive health investigations across India, focusing on cashless claims, reimbursements, travel insurance, critical illness, and personal accident coverage.
- Enabled migration from TPA to internal processing based on recovery findings to streamline operations
Central Coordinator (COE, PAN India head) - Health Claims
Bajaj Allianz GIC
10.2020 - 02.2022
- Supervised 7 direct and 20 indirect employees, overseeing daily operations and ensuring team alignment with objectives.
- Implemented cost-saving measures resulting in ₹125 Crore in savings.
- Investigated PA, travel, reimbursement, and workmen compensation claims to ensure compliance and accuracy.
- Coordinated with IT for AI & software development initiatives
Regional Manager - East & North (Health Claims)
Bajaj Allianz GIC
07.2017 - 09.2020
- Managed government and retail claim portfolios, optimizing claims processing and ensuring timely reimbursements
- Led regional strategy for fraud prevention and claims control, enhancing compliance and reducing risk
- Conducted hospital audits, recovered overbilling, and enforced tariff regulations, ensuring financial integrity
Assistant Manager
Max Bupa Health Insurance
12.2016 - 07.2017
- Assisted in managing daily operations and workflow of health insurance services.
- Coordinated communication between clients and internal teams to ensure service delivery.
- Created initiatives to enhance quality of health claims, resulting in more accurate assessments
- Coordinated nationwide collaboration among field investigation teams to improve investigative outcomes
- Provided support in developing training materials for new hires and ongoing staff development.
Homoeopathic Physician
P.H. Clinic
Patna
11.2014 - 12.2016
- Provided homeopathic consultations to assess health conditions and recommend personalized treatment options, improving client outcomes.
- Established clinic delivering holistic health services, enhancing patient access to alternative treatments.
- Ensured safe clinical environment by adhering to safety protocols and regulations, fostering trust and compliance among clients.
Assistant Manager
Reliance General Insurance
05.2014 - 10.2015
- Achieved highest PAN India savings under Government Business through strategic initiatives.
- Oversaw loss control and hospital networking to optimize operational efficiency.
- Managed RSBY (Kerala/Bihar) & BKKY (Odisha) government schemes, ensuring compliance and effective implementation.
Customer Service Manager
ICICI Lombard GIC Ltd
10.2012 - 05.2014
- Provider Management Manager - RSBY Bihar (8 districts)
- Resolved customer complaints using effective problem-solving techniques to improve customer satisfaction.
- Trained staff on customer service protocols and best practices to enhance service quality.
- Handled customer inquiries across various communication channels to ensure timely support.
Medical Officer
VIPUL MEDCORP TPA Pvt. Ltd
08.2010 - 04.2012
- Led claim processing team for Bihar RSBY at ICICI Lombard Independent Practice, ensuring timely and accurate processing of claims.
- Ensured smooth daily operations to maintain workflow efficiency.
- Contributed innovative ideas and solutions to enhance team performance and outcomes.
- Worked successfully with diverse group of coworkers to accomplish goals and address issues related to our products and services.
Education
BHMS - Medicine And Surgery
R.B.T.S Govt. Homoeopathic Medical College & Hospital
Muzaffarpur12-2009
B.R.A. Bihar University -
Skills
- Claims fraud investigation
- Fraud investigation
- Risk assessment
- Risk management
- Risk & Audit Leadership
- Claims management
- Hospital Audit & Tariff Control
- Pre-Auth & Cashless Control
- Process optimization
- Process improvement
- Operations management
- Team leadership
Custom
BHMS, BU - Reg. No. 28958/2009 (BIH)
Languages
English
Proficient (C2)
C2
Hindi
Proficient (C2)
C2
Accomplishments
Annual Champion of Champions – TATA AIG.
Work Preference
Work Type
Full TimeLocation Preference
On-SiteRemoteHybridSalary Range
₹2400000/yr - ₹4200000/yrTimeline
Vice President - Head, Risk & Audit (Fraud Investigation Unit)
Vidal Health Insurance TPA
11.2024 - Current
AVP - Special Investigation Unit
TATA AIG GIC Ltd
02.2022 - 11.2024
Central Coordinator (COE, PAN India head) - Health Claims
Bajaj Allianz GIC
10.2020 - 02.2022
Regional Manager - East & North (Health Claims)
Bajaj Allianz GIC
07.2017 - 09.2020
Assistant Manager
Max Bupa Health Insurance
12.2016 - 07.2017
Homoeopathic Physician
P.H. Clinic
11.2014 - 12.2016
Assistant Manager
Reliance General Insurance
05.2014 - 10.2015
Customer Service Manager
ICICI Lombard GIC Ltd
10.2012 - 05.2014
Medical Officer
VIPUL MEDCORP TPA Pvt. Ltd
08.2010 - 04.2012
BHMS - Medicine And Surgery
R.B.T.S Govt. Homoeopathic Medical College & Hospital