Fraudsters looking for gaps in the healthcare system are contributing to the rising cost of services, but medical schemes are pushing back to reduce the R28bn or so they’re losing annually from false claims and dishonest behaviour.
Botho Mhozya of Discovery Health told Bhekisisa’s Mia Malan how they’re getting people’s money back, and the implications of this for NHI.
Corruption and fraud is costing the healthcare industry billions every year, and when it comes to the NHI, there are, understandably, huge concerns.
How will the government be able to prevent abuse of a massive pot of money like this if fraud is so rife in the industry – especially with risk and fraud management being the only one of the NHI’s five chief directorates that’s still without a head?
In Bhekisisa’s monthly TV show, Health Beat, Mhozya, head of healthcare delivery transformation at Discovery Health, said between 3% and 10% of healthcare spend worldwide is attributed to fraud, waste and abuse.
At Discovery, recoveries of around R500m represent about 1% of healthcare claims costs. This has a far-reaching impact on affordability of healthcare both locally and globally.
BM: The most common fraud is card farming, when an insured member allows friends or family to use their card to get medical care. Another one is ATMing – when members and a healthcare provider collude. The provider submits a claim to Discovery and then, on receipt of payment, the healthcare provider splits the funds with the member. Also common is submitting false claims for services that were never delivered, and claims that disguise services for cosmetic surgery while understanding that it’s an exclusion within the medical schemes.
For example, someone submits a claim for an appendectomy, but meanwhile they’ve had liposuction.
Discovery’s systems look for outlier trends among claims, and has 44 forensic investigators who analyse and audit claims, supported by 50 more people, like coding, clinical and non-disclosure experts, as well as actuaries and analysts. They look for irregular patterns and over-servicing.
MM: If, for example, someone had plastic surgery and claimed for their appendix being removed, what would that team of analysts do to detect this fraud?
BM: Our reports will often look at a patient relative to their peers. So we would pick up that, for example, certain codes are used more than (among) peers and more than our national benchmarks. Once we’ve picked up that anomaly, we audit the claims and look for suspicious behaviour. We also contact the practices if some untoward behaviour is suspected, or ask for hospital records to ascertain what happened in theatre and look at ancillary claims linked to that medical event (such as from the pharmacy), to get an overview before we call it fraud.
MM: Once you’ve caught a fraudster, how do you deal with them?
BM: We contact the clinician and present our findings, and then allow them to provide supporting evidence. If we then identify a provider as having been fraudulent, a legal process takes place. For blatant fraud, like ATMing or card farming, we have to report this to the HPCSA (Health Professions Council of SA) and the police.
Along with that process, there’s an acknowledgement of debt: if a provider acknowledges they were fraudulent or engaged in wasteful behaviour, a payment process is put into place. All monies recovered through these investigations go back into the trust that holds members’ funds.
MM: What is an example of a recent discovery of fraud?
BM: We recently dealt with a syndicate that involved both member and provider collusion, working across multiple practices. Our analytics were able to quickly pick up the relationship between those practices and the members involved through the auditing process.
MM: Many people are concerned the NHI fund will be a really big pot of money that would be open to corruption and abuse. What kind of rules would you like to see initiated to prevent that from happening?
BM: Fraud exists across all industries, whether public or private. You need robust processes in place to detect fraud in a timely manner and recover those funds. Discovery has a team of experts: forensic investigators, a clinical team, coding specialists, actuaries and analysts, and one would expect a similar composition of skills to detect fraud within the NHI fund.
As a direct impact of the work we do on fraud, we’ve managed to keep contributions 14% lower than what they would be if we didn’t have those processes in place.
See more from MedicalBrief archives:
Fraud, abuse and lazy brokers send SA health costs spiralling
Ramaphosa’s ‘wake-up’ to R22bn in health corruption
Health committee’s new chair says technology will thwart NHI corruption