Medscheme senior clinical advisor, Dr Gregory Pratt

A recent
media report alleging that medical aid claim payments are withheld because a
scheme was under investigation prompted a question from the floor to this
effect as the Fraud, Waste and Abuse Summit drew to a close in Sandton on

“The answer
is yes, we do, but there are different levels of agreement,” said Dr Gregory
Pratt, Medscheme senior clinical advisor when volunteering to provide an answer.

In the first
instance, he said, taking 30 days to pay was not illegal. Requesting info from practices
also took time, often with no response: “We can’t continue funding a practice
when claims are in doubt,” he added.

generally in an earlier presentation on the role of ICT and the challenges
facing schemes detecting fraud, Pratt reported that no less than R150m in
claims covering two million lives were being processed under his organisation’s
administration in a single day.

“There is no
way fraud can be detected in a single claim line,” he said, using the example
of a psychologist claiming a 90-minute consultation: “We have no way of knowing
that the patient was there for 90 minutes. This,” said Pratt, “is why peer
review mechanisms are so important.”

Predictive analytics,
he added, can be used to detect outliers while mathematical algorithms are
applied to assess claiming behaviour and practices.

“However,” he
went on,” abnormal trends usually only develop over time and therefore a lot of
time is needed to investigate.”

Going down to
a clinical level, Pratt noted that the use of data storage programmes such as
Excel prove useful, particularly in preventing a practitioner from trying to
open a new practice after being investigated. Email and telephone numbers on
record, for example, are linked to the practice investigated before: “Can’t get
away with it!

“Data,” said Pratt,
“is therefore very powerful in detecting fraud, waste and abuse and our goal
should be to develop systems to prevent undue losses.”