ERADICATING FRAUD WASTE AND ABUSE IN THE SYSTEM HFMU

Definition of Fraud (Common Law) ‘ Fraud consists in unlawfully making, with intent to defraud, a misrepresentation which causes actual prejudice or which is potentially prejudicial to another.’

Healthcare Fraud “Healthcare fraud involves a deception or misrepresentation that an individual or entity makes, knowing that the misrepresentation could result in some unauthorised benefit to the individual or entity or some other party. The most common fraud involves a false statement or a misrepresentation or deliberate omission which is critical to the determination of benefits” Association of Certified Fraud Examiners – 2009 Fraud Examiners Manual

Healthcare Waste & Abuse Abuse Waste Use or expend carelessly, extravagantly, or to no purpose The use of something in a way that is wrong or harmful Improper or excessive use of something To change the inherent function of something Use to bad effect

THE NATURE OF HEALTHCARE FRAUD Two important factors There is a vast honesty majority Service Providers BUT There are outliers that do significant damage The greatest fraud ‘cost’ comes from High volume / Low value fraud NOT Low Volume / High value fraud

THE NATURE OF HEALTHCARE FRAUD It is reported from some quarters that fraud could be as much as 10% of the cost of all claims. If one considers that about R 130 billion per year is spent on private Healthcare in South Africa then fraud could amount to R 13 billion per year Private Healthcare Fraud in South Africa could be expected to be at least 7%, probably more than 10 % and possibly as much as 15% What is the cost ?

KPMG – Medical Schemes Anti-Fraud Survey

The resilience to Fraud of medical schemes in South Africa August 2013 Jim Gee Director of Counter Fraud Services, BDO LLP Visiting Professor and Chair of the Centre for Counter Fraud Studies at University of Portsmouth, UK

BEST AND WORST Medical schemes performed best in the following areas: 100% of medical schemes have arrangements in place to ensure that suspected cases of fraud, waste and abuse are reported promptly to the appropriate person for further investigation 94.1% ensure that reports about work to counter fraud, waste and abuse are discussed at Board level 94.1% have a formal or informal policy setting out how they try to detect possible fraud, waste and abuse

BEST AND WORST Medical schemes performed worst in the following areas: Only 29.4% of medical schemes use estimates of losses to make informed judgements about levels of budgetary investment in their work countering fraud, waste and abuse Only 29.4% ensure that those working to counter fraud, waste and abuse have received specialist professional training and accreditation for their role

BEST AND WORST Medical schemes performed worst in the following areas: Only 47.1% have arrangements in place to evaluate the extent to which a real anti-fraud, waste and abuse culture exists or is developing throughout their organisation Only just over half (52.9%) regularly review the effectiveness of their counter fraud work against agreed performance indicators

Call for industry collaboration HFMU participation Industry Standards & Guidelines – It outlines the basis of cooperation and collaboration To ensure that the relationship is effective and that together we meet our aims and objectives It sets out principles underpinning the interaction and provides guidance on the exchange of information

HFMU BENEFITS The unit continues to build relationships with the Law Enforcement Agencies (NPA / SAPS) to ensure more efficient prosecutions and to provide them with a better understanding of the medical scheme industry Co-ordination and facilitation of industry investigations to improve the success rate of criminal matters

HFMU BENEFITS To share modus operandi of alleged perpetrators of fraud Holistic view to establish the real cost of Healthcare Fraud Fraud Prevention by means of information sharing Facilitation of training and workshops International exposure, collaboration, access to skills

HFMU OBJECTIVES To eradicate the risks associated with fraud, waste and abuse in the healthcare industry through information sharing.

CASE STUDIES DONE BY HFMU

ALL DIFFERENT SHADES OF HEALTHCARE FRAUD

DENTAL FRAUD

Dental Fraud Over the years, the HFMU members have repeatedly investigated practitioners registered in the Dental Therapy profession The unit then decided to collate all the claims data relating to Dental Therapy over a set period of time in order to obtain an industry view of claiming patterns of the Dental Therapists Once the data had been consolidated and analysed, the HFMU members decided to focus an investigation into the activities of the highest claiming Dental Therapists Investigators and a Clinician were dispatched into the field to speak with patients of these Dental Therapists. The mouths of patients were examined and charted by the Clinician and comparisons were done between the chartings and the claims submitted to the various medical schemes for payment

Examples of Dental Fraud Billing for service not provided Reporting a higher level of dental service than was actually performed – “often called up coding” Submitting a dental claim under one’s patient’s name when services were actually provided to another person Altering claim forms and dental records Billing for non-covered services as if they were covered services Changing the date of service on a claim form so it falls within the patient’s benefit period Routine waiver of a patient’s co-payment or deductible, if applicable Performing services that are not suitable or necessary

EQUIPMENT FOUND IN DENTAL THERAPY PRACTICES

Claimed for 8354 on tooth 42 Post-operative pan shows gold

PROVIDERS PRACTICING BEYOND THEIR SCOPE

EXAMPLES OF AGGRESSIVE BILLING

EXAMPLES OF PROVIDERS TREATING PATIENTS IN/WITH SUB-STANDARD AMENITIES: [Members were treated at a Wellness day in an office of the company]

Case Study: Pharmacists, General Practitioners & members collusion

Wife Pharmacists 4 Brother New Partner Pharmacists 3 Pharmacists 2 Pharmacists 1 Project Funda GP 1 GP 2 GP 3 GP 4 GP 1, 2, 3 GP 1,2 GP 5 GP 6 GP 7 GP 8 GP 9 GP 8 GP 9

Case Study: General Practitioners, Clinic, other disciplines & member collusion

Social Worker Physiotherapist Psychologist Dietician Psychiatrist Pathology Lab Rehab Clinic GP 1 GP 2 New Practice GP 1 / New Partner Ambulance Services

CASE STUDY: Clinical Psychologist

Tariff code summary

What are we doing about healthcare fraud? Collaboration and Information sharing HFMU Member education HFMU Industry Standards Structured approach for consistent application of fraud risk management principles. The Standards also ensure that the industry adheres to the relevant legislation

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