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Healthcare fights fraud

22 May 2018 Gerhard van Emmenis, Bonitas
Gerhard Van Emmenis, Principal Officer of Bonitas Medical Fund.

Gerhard Van Emmenis, Principal Officer of Bonitas Medical Fund.

One of one of the major drivers of healthcare inflation and increased costs is fraud, waste and abuse (FWA) and, although not unique to the healthcare industry, it adds an estimated R22 billion to the annual cost of private healthcare.

To help bolster the fight against FWA in the healthcare industry, Bonitas recently hosted a seminar to share concerns and discuss issues and possible solutions with organisations such as the National Prosecuting Authority (NPA), the Council of Medical Schemes (CMS) as well as service providers.

‘A conservative estimate is that between 10 and 15% of claims contain elements of fraudulent information,’ explains Gerhard Van Emmenis, Principal Officer of Bonitas Medical Fund. ‘Sometimes these are legitimate errors but all too often this is a result of the abuse of member benefits and fraudulent claims as a result of collusion between healthcare practitioners and members.’

‘FWA, has been a key focus for the Scheme. Since 2015 they have adopted a zero tolerance approach and introduced a robust analytical software programme to help identify anomalies and irregularities that could indicate FWA. To-date 35 cases have been investigated with criminal proceedings instituted, other cases are pending but, more importantly R31.2 million has been recovered.

According to Dental Information Systems (Denis), dental fraud is on the rise: Dental therapists are advertising their services as dental practitioners and performing unnecessary procedures as well as cosmetic dentistry, offsetting the costs with multiple claims for fillings, root canal treatment and crowns.

Across the board, including optical and dentistry, the commonality of FWA activity is in the form of:

• Billing for a service not provided
• Reporting a higher level of service than was actually performed – often referred to as up-coding, it’s about using incorrect codes
• Submitting a claim under one patient’s name when services were provided to another
• Altering claim forms and records
• Billing for non-covered services
• Changing the date of a service on a claim form so it falls within a patient’s benefit period
• Waiving of a patient’s co-payment or deductible
• Performing services that are not suitable or necessary (a growing problem in terms of cosmetic dentistry and the fitting of gold and silver inlays)
• Unnecessary or false prescribing of drugs
• Corruption due to kick-backs and bribery.

The general consensus is that the medical fraternity needs to be more vigilant and work together to stamp out FWA. This, by putting more rigorous checks and balances in place as well as educating patients to be more thorough in checking their bills, asking questions about procedures and knowing what their medical aid covers.

Prosecutions and bringing the perpetrators to book is a deterrent. However, Sibonele Cele from the CMS cautioned that healthcare professionals and members have constitutional rights in terms of section 34 of the Constitution. Everyone has the right to have any dispute that can be resolved by the application of law decided in a fair public hearing before a court or, where appropriate, another independent and impartial tribunal or forum.’

He also raised some concerns of possible violations in terms of entrapment when it came to investigations as well as determining the recoverable amount and blacklisting of service providers. He said the CMS would like to see collaboration by all stakeholders across the value chain and an independent and impartial tribunal or forum to adjudicate disputed accounts.

Some advice for clients to avoid being an unwilling participating in FWA

• Keep your personal medical scheme membership details (such as your membership number) private
• Keep your membership card safe
• Check your medical aid statements to make sure that all claims are correct and for services you actually receive
• Make sure the services delivered to you are the same as the claims submitted on your statement
• Avoid any activities where you receive cash back for providing your membership details or other benefits that are not in line with the stated benefits on your option
• Query any irregularities relating to your claims with your broker or the call centre
• Report any suspicions of fraud to the Fraud Hotline on 0800 112 811 - you can remain anonymous

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