Defrauding your medical scheme is not a ‘victimless crime’

Imagine finding out that your pharmacist or doctor has been arrested for submitting an account for care that was not administered, or for overbilling for supplies and services. Imagine finding out that he or she falsified patient data to obtain a higher payments from medical schemes, or had been paid kickbacks to refer patients to a specific specialist or clinic.

These are some examples of medical scheme fraud, which exacts a human and financial toll on our nation.

The loss of funds not only compromises the financial integrity of medical schemes, but also undermines their ability to provide healthcare services to the more than nine million people who depend on schemes.

Medical fraud has directly affected the quality of health care and put some of the most vulnerable patients at risk. Many patients are harmed as a result of unnecessary procedure.

Medical schemes and their administrators are having to spend substantial sums of money on analytical software capable of detecting irregular claims.

Fraud and abuse are rife. It is estimated that at least 10% to 15% of all claims are fraudulent, abusive or wasteful in nature. In a R150-billion industry, that is a substantial expense.

Fraud and waste are defined as intentional deception or misrepresentation, misreporting data to increase payments, paying kickbacks to providers for referring patients for services or to entities, or stealing providers’ or patients’ identities.

Examples of fraud are billing for non-rendered services or supplies, misrepresenting diagnoses to obtain payments and accepting kickbacks.

Abuse includes practices of providers, physicians or suppliers of services that are inconsistent with accepted medical practice, or that are not reasonable and necessary, resulting in unnecessary costs to medical schemes. One of the most common types of abuse involves the miscoding of claims.

Every year, medical schemes are cheated out of billions of rands, which results in higher contributions and co-payments for members.

Healthcare fraud and abuse are hard to contain because of a variety of factors, including the volume of claims associated with a single healthcare event and the emotive nature of “the story” linked to every claim.

Payment by the medical scheme has become an expectation, a right that cannot be denied.

Solutions for stopping medical fraud include: making better use of technology; higher penalties; improved provider enrolment procedures; greater rewards for reporting fraud; educating beneficiaries; and empowering patients and providers so they can identify and report fraud.

Here are some important steps that members of medical schemes can take to ensure that they do not become victims of medical fraud.

• Treat your medical scheme number like your credit card number. Never give it out over the phone unless you initiated the call. If your medical scheme membership card is lost or stolen, report it immediately to your scheme.

• Do not accept free medical services or equipment in exchange for your medical scheme number. Unscrupulous companies or individuals could use this number to bill medical schemes for services or products you did not receive.

• Review your medical scheme statements closely and check for services that you did not receive.

• If you suspect fraud, report it immediately.

Healthcare fraud is not a victimless crime. Every person who pays for healthcare benefits and every business that pays premiums to cover its employees is a victim. • Antoine van Buuren is the chief executive of AfroCentric Group, which owns Medscheme and other healthcare providers.