Abuses in the medical scheme industry

Prevalent types of medical scheme registered cases & who the proponents are

Opportunistic fraud

In terms of rand value this can be relatively low per incident

Small numbers of providers fall victim to the temptation of increasing their revenue

Opportunities due to possible flaws in benefit structure or claims processing

Usually without the assistance of “insiders” / scheme employees

Continues unabated until patterns are detected

Often explained away as “administrative errors”

Professional fraud

Often committed by a group of providers or scheme members

These groups rely on sources within organisations to gain knowledge of anti-fraud cultures and the extent of fraud prevention measures employed

In contrast to opportunistic fraud, this type has a lower incident rate, but a much higher rand value

Sharing of member information among a group of providers is common

Member apathy – not scrutinising remittance advices

Examples of fraud and abuse

Over-servicing

Duplication of claims

Unbundling – incorrect reporting of diagnoses/procedures

Tariff manipulation and up-coding – improper coding to obtain a higher payment

Alteration of treatment dates when benefits are exceeded

Unnecessary treatments/procedures/medicines

Fictitious claims – billing for services not rendered

Examples of fraud and abuse Collusion between patient and healthcare provider

Claiming for procedures excluded from benefit

Corruption = kickbacks and bribery

Generating claims for non-existent equipment

“Sharing” of medical aid cards

High cost driver in the industry

Skews disease profiles

Medico Legal complications where a death occurs

Examples of fraud and abuse

Claiming ICU tariffs when patients were in general wards

Inaccurate reporting of theatre time

Nondisclosures

Dual membership

PERPETRATORS?

Medical professionals

Medical scheme members

Medical scheme employees

The man on the street selling sick notes

REMEMBER

Upgrade your technology - Prevention is better than cure

Create awareness

Form a united front in the fight against white collar crime

Collaborate

Analyze your strengths and weaknesses

_____________________

Fraud and corruption occur whether systems are predominantly public or private, well funded or poorly funded and technically simple or sophisticated. No country is exempt. Fraud effects every kind of healthcare system.

011 537 0227

lynettes@bhfglobal.com

THANK YOU