While the monetary losses incurred by fraud, waste and abuse (FWA) represent the biggest industry challenge, directly related problems such as compromising the quality of care and patient management are equally concerning.
Making this point, long-serving head of forensics at Discovery, Marius Smit, told FWA Summit delegates of a serious case of what he referred to as “fabricated dispensing” in which it was found that a general practitioner allegedly dispensed Voltaren for every patient – including those with diagnoses for influenza, rhinitis depression and abdominal pain.
He also referred to the alarming number of patients being admitted to hospital unnecessarily: “Hospital is a great place if you are sick but not so great if you are not…!”
“I would like to stress here, however, that fraud and abuse is not only a doctor problem. We see it across all disciplines,” he added, displaying a forensic trends slide featuring no less than 26 disciplines including hearing aid acousticians, dieticians, as well as dental, occupational and speech therapists.
“But here I must emphasise that the vast majority of healthcare providers are honest, hardworking, highly ethical professionals who deliver diligent care to their patients. This is shown by the fact the average forensics/saving recovery vs. claim paid per discipline is only 1, 33% and that the average ration forensic case count vs. billing practices is 9, 9%.
“It is therefore only a minority of ghealthcare professionals who commit FWA against medical schemes which,” he said, “unfortunately results in huge costs to schemes and their members.”
To put this in perspective, Smit reminded his audience that schemes by law had to maintain a 27% solvency rate: “But FWA amounts to 16%. So in real terms they would have to increase their premiums by 14% to cover these losses. Very challenging!
“Being in this business for more than 20 years now,” Smit concluded, “I have seen many initiatives being introduced to combat the scourge of medical aid fraud. I am encouraged by this one by the Council for Medical Schemes and hopefully the collaboration intended has the desired effect.”