Dr Syed Affan

BHMS Doctor and Medical Audit Consultant with strong experience in private health insurance, hospital audits, cashless and reimbursement investigations, claim settlement, clinical case review and hospital billing analysis. Strong knowledge of medical terminology and clinical documentation, with the ability to identify billing discrepancies, fraud, overcharging, unbundling and non-compliance with agreed hospital tariffs and MOUs. Successfully recovered lakhs of rupees for insurance companies by identifying discrepancies and fraudulent billing practices by hospitals.

Medical Audit Consultant at Health Insurance / Hospital Audits (Present)

• Conduct cashless and reimbursement claim investigations by reviewing clinical records, final bills, discharge summaries and supporting documents.
• Support claim settlement through assessment of medical necessity, treatment documentation, billing accuracy and policy/tariff compliance.
• Audit empanelled network hospital bills to ensure strict compliance with contracted pricing matrices, MOUs, packages and approved tariffs.
• Identify hospital billing discrepancies, overcharging, unbundled billing, duplicate charges, non-payable items and documentation inconsistencies.
• Utilize clinical logic and strong knowledge of medical terminology to identify potential Fraud, Waste & Abuse (FWA), phantom billing, unnecessary hospitalizations and treatment upcoding.
• Engage with hospital administrations and claims teams for query resolution, dispute management, refunds and financial recovery.
• Recovered lakhs of rupees for insurance companies by identifying billing discrepancies, non-compliance and fraudulent practices by hospitals.
• Support hospital empanelment, contract renewals, provider grading and healthcare facility audits.
• Assist with pricing negotiations, package and discount validation, tariff analysis and provider relationship management.

RMO at Aryan Hospital, Mumbai (2021-01 – 2024-12)

• Provided medical assessment and clinical support in hospital and emergency care settings.
• Coordinated patient care, investigations, treatment plans and clinical documentation.

ICU Resident Medical Officer at Habib Hospital (2015-01 – 2021-12)

• Worked in ICU and casualty settings with responsibility for patient monitoring and clinical support.
• Assisted with examinations, procedures and treatments.
• Worked in rapid-care settings to triage patients, take vital signs and assist with patient care.

Assistant Cardiologist at Hamdulay Heart Foundation, Habib Hospital (2018-01 – 2018-12)

• Assisted the cardiology team with patient examination, investigations, procedures and monitoring.

BHMS – Shree Janata Medical College, Akola, Maharashtra (2013-12)

CCMP – Government Medical College, Akola, Maharashtra University of Health Sciences, Nashik (2023-01 – 2024-12)