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SUB CATEGORIES General  |  HIV |  Medical Schemes | 

The old brush...

17 May 2004 Angelo Coppola

There is little that excites the press, the public or the member more than a juicy fraud story, says Gary Taylor, MD of the group services division of Medscheme.

At the same time, it annoys and disappoints the honest medical practitioner that such publicity tars all doctors with the same brush. Here is a Medscheme perspective.

Just how big is the problem?  The honest answer is that we don’t know, and can only speculate.  Furthermore, how do you distinguish between fraud and over-servicing?

What is going on?  Well, here are a few instances Medscheme has uncovered:

* dentists billing for crowns when they are doing gold or diamond inlays;

* optometrists billing for specs, but dispensing designer sunglasses;

* radiographers using an ultrasound over the skull, and charging for a brain scan;

* pharmacists switching generics for an ethical prescription and charging for the brand name;

* specialists using a GP as a locum;

* GPs owning a butchery and dispensing meat.

The Medscheme Fraud Unit recovered R 40.8m from doctors last year alone, and paid this money back to the schemes it administers.  This figure did not include the millions more denied at assessing stage, or prevented through managed care programmes.

“In reality, there are three levels we work at,” says Taylor.

* CIVIL action to recover monies.  This entails the recovery of fraudulently claimed money back to our schemes.

* CRIMINAL action to lodge a watertight case with the SAPS, and prosecute through the criminal justice system.

* PROFESSIONAL action to get the Health Professions Council of SA to deregister a person from practicing in future.

This is certainly an area where Medscheme’s size works for its clients.  If we remove a doctor from direct payment, we do it for all of our schemes.  With 39% market share, this really affects a doctor’s cash flow, and we get an immediate change of behaviour.

Reaction from the profession has been encouraging.  Most honest doctors want the bad eggs removed as much as we do, because all the fraud publicity is bad for the entire industry reputation.

“What is gratifying is the number of honest members and honest practitioners who use the Medscheme Fraud Hotline on 0800 11 28 11 to report fraud. 

“This is wider than just our company, and late last year, we handed over more than R1m we had recovered for Medihelp, and worked with Discovery to arrest two staff we had fired for fraud who were working for them under false pretences.

“What is also pleasing is to see schemes adopting a zero-tolerance attitude against fraud. 

“Barloworld took a case of card lending through to Labour Court, while larger schemes like Bonitas and Medshield have been prepared to fund special investigations and legal fees to unearth organised syndicates, and prosecute to the full extent of the law.

This has included co-operation with Interpol and Scotland Yard.

“When our industry takes a tough stance is when the crooks will reconsider their behaviour. 

"There are enough legitimate causes of healthcare inflation for us to deal with, let alone having fraudsters strain the system.”

Quick Polls

QUESTION

There are countless articles written about South Africa’s poor retirement outcomes. Which of the following would you single out as the biggest contributor to local savers not accumulating enough to buy an adequate and sustainable pension?

ANSWER

Lack of personal accountability
Poor participation in formal retirement funds
Reluctance to seek financial advice early on
SA’s high unemployment rate
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