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
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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.