The trade-craft medical service provider compliance issues and fraud investigation

Following our previous submission outlining MedSeCo’s services, we present a synopsis and analysis of findings from our compliance investigations into medical services misrepresentation, fraud, waste, and abuse over the past two years. This analysis draws on information gathered from various sources, including outliers, data analysis, scheme financial reporting, and tip-offs. While most healthcare providers demonstrate dedication and integrity in prioritising patient well being, instances of fraud and abuse within the system are concerning and require attention.

Medical doctors and dentists

Doctors contracted by private companies for employee health assessments may pressure workers into completing medical claims forms, facilitating fraudulent claims for services already paid for. Some doctors perform surgeries not supported by medical evidence or guidelines, such as unnecessary caesareans or spinal fusion surgeries, solely for financial gain.

Dentists exploit billing codes charging for a crown or bridge instead of a standard filling or using codes for extensive treatments like periodontal scaling and root planning for basic cleanings. They may also collude with patients to falsely represent the need for costly treatments like gold implants.

Laboratory diagnostics and radiology

Some laboratories exploit billing codes by claiming reimbursement for more complicated tests instead of basic blood tests like full blood counts (FBC) and will submit claims for more extensive panels like metabolic or comprehensive metabolic panels (CMPs). This allows them to receive higher reimbursements for tests they didn’t perform.

Similarly, radiology centres may bill for basic imaging studies like X-rays but use codes for advanced modalities such as MRIs or CT scans, inflating reimbursements for services not rendered or less sophisticated than billed. This not only drives up healthcare costs but also compromises billing accuracy and patient records.

Optometry and audiology

Medical complimentary fraud encompasses deceptive practices in both optometry and audiology services. Some optometrists collude with patients to submit claims for non-medical items like luxury sunglasses or jewellery, or they even provide members with cash payments, fraudulently billing medical schemes for covered benefits.

Similarly, in audiology, fraudulent practices may involve billing for unnecessary hearing aids or services not rendered. This could include billing for expensive hearing aids or accessories that are not medically necessary or misrepresenting the severity of a patient’s condition to justify higher fees.

Physiotherapy and occupational therapy

Collusion between physiotherapists and gymnasiums involves routine gym exercises being falsely billed as therapy sessions, which can lead to false billing practices and normal physical activities at the gym being misrepresented as physiotherapy sessions. This fraudulent behaviour results in unwarranted claims being submitted to medical schemes.

With occupational therapy, services may involve a syndicate with an orthotist and prosthetist, who may recommend and bill for unnecessary equipment, aids, or supplies, such as specialised ergonomic tools that are not essential for the patient’s rehabilitation.

Pharmaceutical

Pharmacists sometimes submit claims for products or services that fall outside the coverage provided by the medical scheme. Despite being excluded, these items are still supplied to patients. Examples include beauty and cosmetic products, toiletries, and other non-medical items such as AMC cooking pots and Tupperware. This practice leads to the misuse of medical aid funds and undermines the integrity of the healthcare system.

Ambulatory services

Ambulance services can engage in fraudulent practices by billing for unnecessary waiting periods. For instance, situations arise where members, though only slightly injured, wait for non-medical reasons, such as waiting for family members, police, or tow trucks. The ambulance driver takes advantage by waiting so that they can bill for a waiting period. It’s crucial for medical schemes to scrutinise such claims carefully, ensuring that billed services align with genuine medical needs

Conclusion

Medical and healthcare fraud can manifest in various forms and is challenging to detect. It involves fraudulent actions by both providers and consumers, ranging from false claims to collusion schemes.

MedSeCo’s investigative efforts have identified numerous instances of fraud, including false claims, irregular billing, and provision of unnecessary services. Addressing these issues is crucial to safeguarding the integrity and sustainability of medical schemes.