Collaboration needed to combat medical aid fraud - experts

Cape Town - Fraud, waste, abuse, and irregular payments within the healthcare sector are slowly crippling the industry, said the Board of Healthcare Funders (BHF).

At the recent BHF conference in Cape Town, delegates agreed that there is a deep need for increased collaboration between stakeholders throughout the healthcare industry and related investigative services to effectively tackle fraud and waste.

“Fraud represents a material threat to the affordability and sustainability of medical schemes and also for any future NHI initiatives,” said Gregory Pratt of Medscheme’s forensic unit.

He added that if something isn’t done soon the affordability of schemes will reach a tipping point that will place too much economic pressure on young and healthy members, causing that essential supporting element of the industry to leave schemes and potentially collapse the industry.

READ: Fraud costs private healthcare R22bn - SIU 

Among some of the reasons given for the increase in fraud and irregular pricing, Pratt pointed to practitioners having a sense of entitlement in charging inflated amounts around Prescribed Minimum Benefit (PMB) cases, the infiltration of organised crime syndicates into the healthcare industry because it presents a soft target, and a desire to meet certain lifestyle aspirations.

Special Investigating Unit (SIU) head Andy Mothibi highlighted the importance of establishing methods that will bring together all possible stakeholders within the healthcare sector in order to tackle the issue and accelerate investigations into practitioners facilitating corrupt activities, emphasising the role played by “whistleblowers” in the success of such investigations.

He highlighted that the SIU is looking to “whistleblowers” to continue providing information to the SIU in order to tackle fraud, waste and abuse.

READ: Ramaphosa slams corruption, says 'house is burning' in SA

Mothibi proposed that investigation and prosecution proposals should be referred directly to President Jacob Zuma for approval. From there the entire process would be enabled through direct collaboration with numerous agencies across the board, including the criminal justice agencies, constitutional and other public oversight bodies, including the Public Service Commission, Public Protector, Parliament’s standing committee on public accounts (Scopa), Independent Police Investigative Directorate (IPID), the Inspector-General of Intelligence (IGI) and The Competition Commission.

“Of importance is to ensure that anti-corruption efforts should create a system that can operate freely from political interference and can be supported by both public officials and citizens.”

Proposed solutions

Pratt urged stakeholders to utilise “big data” analysis technology to accelerate the identification of anomalous claiming patterns, allowing earlier and more decisive interventions, as well as to correct system vulnerabilities.

There is a need to push for much stronger vetting when it came to matters such as the issuing of medical practice numbers – especially when additional numbers are issued to the same practitioner.

He used the example of some healthcare professionals having as many as six practice numbers while operating from a single practice location.

“When a medical scheme blocks a practice number due to confirmed fraud, the practitioner is currently able to obtain a new one with little difficulty.”

Pratt added that the fragmentation of the industry itself was contributing to its actual and perceived vulnerability to fraudsters, and proposed that industry stakeholders make a concerted effort to collaborate and share information, not only on fraudulent practitioners but also on preventative methodologies.

Medical schemes will also be taking strong first steps in better utilising the services of agencies such as the SIU.

READ: Can a medical scheme fire a member for fraud? 

Mothibi called on the healthcare industry to “fight the scourge together,” in order to realise the SIU’s stated goal of “zero corruption tolerance” by the year 2030.

“We know this will not be an easy challenge, considering that sub-Saharan Africa currently sits at the bottom of the Corruption Perceptions Index, but by systematically isolating problem areas, keeping abreast of the ‘evolving technological landscape’, and developing memorandums of understanding with bodies such as the Council for Medical Schemes (CMS), Health Professions Council of South Africa (HPCSA), and BHF (Board of Healthcare Funders), the goal is attainable.”

Collaborative efforts crucial

Using the anticipated procurement activity within South Africa’s National Health Insurance (NHI) as an example, he emphasised that establishing collaborative mechanisms such as those memorandums is urgent.

Kgosi Letlape, President of the Health Professions Council of South Africa (HPCSA), said he is not “happy” that people are being paid who are manipulating the system.

“We need to go back to basics, and review the process of issuing practice numbers. The BHF has a big role to play in addressing this. We also need to revise the regulatory framework.”

He suggested medical scheme administrators take more stringent measures to make sure that what health practitioners claim is correct, and in instances of suspicious activity, administrators must request proof from practitioners to show that people were in fact ill. 

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