Why would two families claim over 30 thermometer units, which cost about R3 200 each? Or 11 nebulisers? What about four swivel bath chairs, costing approximately R2 000 per unit?
The 'halo effect'
These are just some of the fraudulent pharmacy claims that Discovery Health uncovered last year when it recovered R400 million on behalf of its client schemes, Discovery Health CEO Dr Jonathan Broomberg told Health24.
Discovery Health’s Forensics department deals with more than 3 000 forensic investigations per year.
"In cases where there were abnormal claims patterns and we have intervened we’ve noticed a positive shift in the claiming behaviour of healthcare providers to normal levels. We term this the halo effect and estimate this to be a cumulative R1 billion saving, which could be termed ‘prevention’."
Dr Broomberg said Discovery Health has invested substantial resources in fighting fraud, including deploying an extensive, specialised team of analysts and professional investigators, as well as using an in-house proprietary forensic software system.
"Informa™ uses smart, dynamic algorithms to trawl through all our schemes claims data on a daily basis to identify any unusual patterns and flag items for further investigations," he said.
"We view fraud as a serious criminal offence, and we take all actions necessary and where appropriate to counter fraud including creating awareness through presenting at several healthcare conferences, advertising on employer intranets, placement of posters and books at various healthcare practices."
Fraud claim hotspots
Although the vast majority of scheme members and the professionals and businesses who serve and treat them are honest, hardworking and ethical, Dr Broomberg said a small minority are tarnishing the reputation of the healthcare system and causing significant financial losses.
He noted a case in the past year where hospital cash plans were abused by patients and doctors to claim money from the medical scheme.
"Doctors were identified who were admitting patients to hospital that were not ill, then submitting false claims on their behalf to both their medical scheme and their cash plan provider. The 'patient' would then split the cash lump sum paid out by the insurer with the doctors," said Dr Broomberg.
When asked what the fraud claim hotspots were, he named six frequent fake claims:
1. Doctors submit claims for services that have not been rendered to patients.
2. Dispensing doctors and pharmacies provide members with low cost generic medicines and claim for higher cost brand name medicines.
3. Doctors provide fraudulent sick notes to members and then claim for a consultation from the scheme.
4. Pharmacies sell cosmetics and other “front shop” items to scheme members, and submit fraudulent claims for medicines to the scheme.
5. Members, in collusion with doctors and hospitals, submit claims for false hospital admissions, in order to benefit from the claims payment.
6. Members forge and submit claims for services supposedly rendered by healthcare professionals, but which were never actually rendered.
What happens to members and medical professionals involved in fraud?
When fraud is identified and proven, Discovery Health takes a number of actions, explained Dr Broomberg.
The scheme reclaims the monies obtained fraudulently by members and healthcare providers, and which are owed to the medical scheme. The scheme then terminates memberships of clients and payment to healthcare providers in the cases of proven fraud and they also file formal charges of fraud where appropriate with the South African Police Services.
Regarding fraud by medical professionals, Discovery Health submits formal complaints to the Health Professions Council of South Africa (HPCSA) where appropriate. "The HPCSA has jurisdiction then decides whether to dismiss or suspend a healthcare professional according to the merits of the case," Dr Broomberg said.
Image: Medical aid from Shutterstock