Abuses in the medical scheme industry

1. Abuses in the medical scheme industry Prevalent types of medical scheme registered cases & who the proponents are

2. Opportunistic fraud • In terms of rand value this can be relatively low • per incident • Small numbers of providers fall victim to the • temptation of increasing their revenue • Opportunities due to possible flaws in benefit • structure or claims processing • Usually without the assistance of “insiders” / scheme employees • Continues unabated until patterns are detected • Often explained away as “administrative errors”

3. Professional fraud • Often committed by a group of providers or scheme members • These groups rely on sources within organisations to gain knowledge • of anti-fraud cultures and the extent of fraud prevention measures • employed • In contrast to opportunistic fraud, this type has a lower incident rate, • but a much higher rand value • Sharing of member information among a group of providers is • common • Member apathy – not scrutinising remittance advices

4. Examples of fraud and abuse • Over-servicing • Duplication of claims • Unbundling – incorrect reporting of diagnoses/procedures • Tariff manipulation and up-coding – improper coding to • obtain a higher payment • Alteration of treatment dates when benefits are exceeded • Unnecessary treatments/procedures/medicines • Fictitious claims – billing for services not rendered

5. Examples of fraud and abuse • Collusion between patient and healthcare provider • Claiming for procedures excluded from benefit • Corruption = kickbacks and bribery • Generating claims for non-existent equipment • “Sharing” of medical aid cards • High cost driver in the industry • Skews disease profiles • Medico Legal complications where a • death occurs

6. Examples of fraud and abuse • Claiming ICU tariffs when patients were in general wards • Inaccurate reporting of theatre time • Nondisclosures • Dual membership

14. PERPETRATORS? Medical professionals Medical scheme employees Medical scheme members The man on the street selling sick notes

15. REMEMBER • Upgrade your technology - Prevention is better than cure • Create awareness • Form a united front in the fight against white collar crime • Collaborate • Analyze your strengths and weaknesses • _____________________ • Fraud and corruption occur whether systems are predominantly public or private, well funded or poorly funded and technically simple or sophisticated. No country is exempt. Fraud effects every kind of healthcare system.

16. THANK YOU 011 537 0227 lynettes@bhfglobal.com