Fighting fraud in the healthcare industry

Gerhard Van Emmenis, Principal Officer, Bonitas Medical Fund

Fraud, waste and abuse are some of the biggest contributors to escalating healthcare costs in South Africa. Curbing their impact remains a top priority for Bonitas Medical Fund, says its Principal Officer, Gerhard Van Emmenis. An advanced analytical software system, introduced by the Scheme in 2016, is already helping enhance the detection and prevention of fraud, wastage and abuse.

“The recent conviction of three bogus medical technologists in Limpopo is very positive for us as a Scheme, our members and the healthcare industry generally,” Van Emmenis adds.

“These convicted criminals, who collaborated with medical doctors to pay for unnecessary tests, were collectively found guilty of 1 448 counts of fraud, totally over R1.3 million over a period of 10 years. However, thanks to a tip off, Bonitas analytics and thorough investigations, the Hawks and SAPS were able to bring them to justice and all three will be serving jail terms.”

According to Section 66 of the Medical Schemes Act, medical aid fraud, committed either by a member or a healthcare practitioner, is a criminal offence which carries a fine or imprisonment or both. In the instances where a healthcare provider is guilty of committing fraud, all fraudulent claims are reversed and the provider is reported to the relevant regulatory body and a criminal case opened.

A member found guilty of committing fraud will have their membership terminated. All fraudulent claims submitted will be reversed and the member will be liable for them. A criminal case will also be opened. In addition, members who commit fraud may also have their employment jeopardised – especially in cases where their medical aid contributions are subsidised by their employer.

Successful fraud recovery

As at the end of December 2016, after the implementation of Phase 1 by Bonitas which looked at live billing, the Fund had identified R79 million in fraud, waste and abuse and recovered around R20 million from healthcare professionals. Out of the 574 healthcare professionals identified, 34 have been charged and there have been four successful arrests.

“The repercussions of fraud are widespread but it has a very direct impact on each and every member of the Fund,’ explains Van Emmenis. ‘Medical schemes are owned by their members and when money is defrauded from the Scheme it can contribute towards increased premiums. In fact the money we recovered last year could have been used to pay for around 57 000 more GP consultations.”

It is estimated that in the South African private healthcare industry around 10-15% of claims contain elements of fraudulent information – adding an additional R22 billion to costs.

Members need to be vigilant

“We recently introduced Phase 2 and 3 of our fraud detection initiatives which focus on pharmacies and hospital claims,’ says Van Emmenis, ‘However we believe that our most invaluable tool against fraud, waste and abuse remains our members. To assist them to be proactive in joining us in the fight we have a toll-free fraud hotline (0800 112 811) to report any incidents of suspected fraud, waste and abuse and encourage them to use it.

“In our experience, the biggest single deterrent to fraud, waste and abuse is making it known that we are actively investigating every suspicious or unusual claim or activity. Education in terms of the relationships with medical aids, their members and the healthcare providers goes a very long way in curbing the abuse of medical aid benefits and, as such, our approach to fraud management speaks to this education component in all the matters we deal with.”

Who are the culprits?

The culprits are not just medical practitioners. Guilty parties are found all along the healthcare delivery chain – from medical practitioners through to employees, service providers and members.  There has also been an increase in collusion between members and healthcare providers.

The trends

Van Emmenis says fraud may not necessarily be on the increase but the high level analysis means medical schemes are uncovering substantially more fraud than previously. Current trends seem to be phony doctors or medical practitioners who submit claims, using another doctors’ practice number. Sometimes this is done in collaboration with members.

Other fraudulent activity

Waste and abuse is far higher than fraud and is more easily quantifiable in terms of values as it is usually a clear contravention of tariff codes or a rule that exists. Most of the common practices include:

  1. Billing for services not rendered (over billing)
  2. Using incorrect codes for services (at a higher tariff)
  3. Waiving of deductibles and/or co-payments
  4. Billing for a non-covered service as a covered one
  5. Unnecessary or false prescribing of drugs
  6. Corruption due to kick-backs and bribery

Here are some tips of members of medical aids to help prevent fraud

  • Keep your personal medical scheme details (such as your membership number) private
  • Check your medical scheme statements to make sure that all claims are correct and that you actually received the services you are being charged for
  • Keep your membership card safe
  • Report any suspicious activity by calling 0800 112 811

“We are encouraged at the increased reports by our members. Fraud directly impacts them so we all need to be more diligent in checking our billings and questioning unnecessary procedures. The contribution by members, combined with our internal fraud-tracking system and investigations by the Hawks will all work together to put a stop to fraud, wastage and abuse and help reduce spiralling healthcare costs. It’s a win-win for everyone,” says Van Emmenis.

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