KZN tops the list for HCBP fraud
Medical schemes abused
KWAZULU- Nat al ’ s private health practitioners have defrauded millions of rands from the Government Employees Medical Scheme (Gems), the scheme said yesterday.
Recent and ongoing investigations by Gems forensic investigators this year uncovered suspected fraud by some healthcare service providers and Gems members. Gems principal officer, Dr Guni Goolab, said KZN had the highest prevalence of fraud and abuse of the hospital cash back plans (HCBPs). The scheme, he said, launched a full-scale investigation in the province.
This followed a comprehensive review of claims submitted by various service providers and includes a number of in-hospital claims.
Goolab said they uncovered a number of instances where claims were irregular or questionable.
In KZN, he said, two physiotherapists signed acknowledgements of debt for R502 000 and R350 000 respectively. Other debt acknowledgements included a dietitian for R150 000; four psychologists for R240 000, R600 000, R1,5 million and R2 million respectively; two physicians for R700 000 and R2 million; and a surgeon for R3 million.
He did not elaborate on the cases as investigations were ongoing.
“There were a number of claims relating to hospital admissions where either the length of hospital admission was unnecessarily extended or found to be without clinically appropriate reasons.
In certain cases, the patients did not undergo any significant pathology or radiology tests following their admission to hospital. This was even in instances where the patients were reportedly seriously ill,” said Goolab.
He said the irregular claims were used specifically as “a vehicle” to obtain benefits associated with HCBPs.
Scheme
This essentially means that the medical scheme was used to fund medical conditions that could either have been treated within a shorter period, more effectively with alternative treatment regimes or which were potentially never necessary in the first place, he said.
He said different insurance schemes offered the HCBP plans for a monthly premium.
“Since no qualifying criteria exists to buy this plan, other than being able to pay the monthly premium, it has become a target for unscrupulous individuals.
This, unfortunately, leads to medical schemes often funding medical expenses that are not necessary, thereby placing undue pressure on the financial resources of medical schemes and unfairly disadvantaging members who are in real need of appropriate medical care. It also artificially increases costs,” he said.
The doctor said affidavits obtained, including data analysis, indicate that there was sufficient evidence to warrant pursuing criminal charges against certain individuals and institutions. He said they had also reported cases to regulatory bodies, including the Health Professions Council of South Africa (HPCSA).
A major consequence of the abuse of HCBPs would be higher premiums.
HPCSA spokeswoman, Daphney Chuma, said fraud by registered practitioners was considered unprofessional conduct in terms of the Health Professions Act.
She said they would institute an inquiry once they received complaints.
The South African Medical Association acknowledged that “bad elements” existed in the health-care sector.
Chairman Dr Mzukisi Grootboom said some people treated medical aid cards as supermarket cards. “What these people don’t realise is that medical aid coverage is meant to be a cushion for when they encounter unexpected illnesses. Unfortunately, there are bad elements who assist these people to make illegal claims from their schemes.”
He felt it was unfair for medical aid schemes to blame healthcare practitioners in general as perpetrators of this crime were known.