Discovery Health’s efforts to curb fraud, waste and abuse (FWA) in the healthcare system resulted in a substantial R555m recovered on behalf of client schemes last year, DHMS CEO, Dr Jonathan Broomberg, announced in a media release this week.

Regions with the highest number of FWA cases investigated in 2018, he noted, included the Limpopo province which topped the list (201 cases per 100,000 DHMS lives – down from 226 cases per 100,000 DHMS lives in 2017), followed by Free State (89 – up from 55 cases in 2017) and the North West (89 – up from 70 cases in 2017).

FWA cases were also investigated in the Eastern Cape (85– up from 70 cases in 2017), Gauteng (83 – up from 73 cases in 2017), Kwa Zulu Natal (79 – up from 72 cases in 2017), Mpumalanga (66– down from 95 cases in 2017) and the Western Cape (53 – up from 47)

The least number of cases investigated in 2018 emanated from the Northern Cape (33– down from 52 in 2017).

Types of FWA cases identified in 2018 were:

·         Claims submitted for services not rendered (40%)

·         Capturing errors by a practice (16%)

·         Procedural codes applied incorrectly by healthcare providers – e.g. using a code that carries a higher value than the service performed (12%)

·         Outlier trends are identified for a practice – an audit is needed to verify claims (11%)

·         Duplication of claims (6%)

·         Claims by non-members (4%)

·         Claims for more expensive items or items different to those supplied (4%)

SOURCE: Discovery News Media Relations Team