Section 59 Submission – SAPPF & FCPSA

1. Section 59 Submission – SAPPF & FCPSA Dr Adri Kok MBBCh, Dip PEC, FCP(SA), MMed, FACP, Btheol, FRCP (London) SAPPF Director FCPSA President

2. Fraud, Waste & Abuse Definitions • Fraud: A range of behaviour where there is wilful misrepresentation • Waste: Useless expenditure or consumption • Abuse: Acts that are inconsistent with sound medical or business practice

3. Discussion Points • Coding in SA • Reasons for Investigations • Disciplines involved • Racial Profile of Membership • Typical Problems with Forensic Investigations • Data Sharing and Data Analysis • Demographic analysis of physicians who were investigated • Process followed with Forensic Investigations

4. Coding in South Africa • For many years: Coding "impasse” in the industry • Changes in descriptors, deletion of obsolete/old, additions of new codes for new procedures or technology • Many medical schemes do not accept coding changes 2006 – 2016 • Revert back to RPL 2006 for forensic investigations • Differences in opinion on interpretation & application • Bottom line: Coding in SA is not perfect • SAMA Medical Doctors Coding Manual (MDCM) should be the standard.

5. Reasons for Individual Practice Audits • If you deviate from the norm • Services not rendered, but claimed for • Level of Acuity - ICU & HCW • Combination of Codes incorrect • Upcoding or unbundling • Incorrect application/interpretation of codes, e.g. emergencies • 7. Polypharmacy • Patient complaints • Total time spent per day • Fraudulent behaviour including collusion with patients 12. Consistent use of longer psychotherapy goods & group therapy

6. What triggers a forensic investigation? • Hotlines for Informants / Whistle-blowers • Member complaints or complaints by other doctors • Medical rules based detection software and internal controls • Internal Forensic Investigative Units of schemes/ administrators • Often, innocent errors, can trigger a full-on investigation • Routine audits done by medical schemes and administrators • Per discipline, e.g. psychiatry, ophthalmology • Per code, e.g. 0146, 0147, Rule M, Rule G, etc • Deviation from the norm/outlier profiles compared to peers • Combination of codes • Higher than “normal” utilisation of specific codes

7. Racial Profile of Membership • SAPPF & Societies do not request the race of a healthcare professional when members join the organisations. • Membership forms and documents do not have a field for “race” to be completed. • Not possible to determine the race of members accurately • Guestimate based on surname • It is therefore not possible to provide a racial profile of the membership base, that is 100% accurate. • However, for the purposes of this submission, demographic data was analysed and the following profile of physicians, who have been investigated, can be provided.

8. Demographic analysis of Physicians Membership

9. Typical Problems with Forensic Investigations • Medical schemes/administrators make the rules regarding investigations. • They determine who should be investigated. • They carry out the investigation themselves. • They employ their own methodology dictated by auditors . • They do not share the data to verify that a healthcare professional is an outlier. • They then make a finding of who is guilty or not. • They then impose the sanctions.

10. Data Sharing & Data Analysis • Medical Schemes have access to data but are not willing to share it with the profession. • When assisting a doctor with a forensic audit it is imperative to do a full data analysis in order to understand the issues and to verify the coding in question and recovery. • When we as doctors have had an opportunity to evaluate the veracity of these “outlier” data we have repeatedly found data wanting

11. FCPSA: Investigations on physicians • FCPSA has been aware of forensic investigations/ audits/ reviews of physicians since 2013 • Over the last 6 years, there has been 22 audit cases in which physicians requested assistance • Others have opted not to approach FCPSA when being investigated - resolved their investigations on their own or with external legal assistance. • It is therefore not possible to accurately determine the exact number of physicians who were investigated by medical schemes/administrators and FCPSA can only report on a portion of investigation.

12. Demographic analysis of FCPSA Membership vs Forensic Investigations

13. FCPSA: Outcomes of Investigations

14. Process followed in the Forensic Process • Ensure mandate is in place in order to assist • Request all information received from the investigating party • Determine the issue at hand • Request expert coding opinions • Profession’s Coding Committee • Coding Experts • Compare expert coding opinion with investigating party’s findings • Check the accuracy and interpretation of auditors’ findings

15. Steps in the Forensic Process relating to the Data Analysis • 7.Validate investigating party’s calculation or do own calculation to validate/disprove their findings • 8.Communicate outcome to Practice/Provider • 9. Meet with Provider • 10.Discuss the findings in detail with provider in presence of coding committee and society representatives • 11.Present the impact of our data analysis • 12.Engage with investigating party regarding resolution • 13.Provide ongoing coding support and mentorship to provider via Society/Management Group

16. Other Analysis • Are usually unique and case specific but include: • Rule M (Can’t Bill consult with planned Surgical Procedure) • Rule G (Can’t Bill consult with Post-op Care, included in Procedure) • Combinations not allowed together • Unbundling of Codes • 0145 to 0148 incorrect applications and interpretations • Multiple providers billing for the same service • Incorrect NAPPI Codes • Modifiers not applied correctly • 0005 – multiple procedure under same anaesthetic • 0008 and 0009 – GP/Specialist Assistant • 0011 – emergency Surgery • 0013 – Laparoscopic procedure modifier

17. Specific examples of Forensic Issues • Rule G : Global period of aftercare 4 weeks • Various investigations where physicians treated patients • Scope of Practice: Dr JR • Cardiac ultrasounds • Done for almost 30 years • Indicated: No qualifications and acting Out of Scope of Practice • Suspended direct payment • Codes 3620,  3621, 3622, 3625 and others • Qualifications: SA Qualified Internal Medicine FCP (SA) 1978 • Oxford University, M.R.C.P. (UK) 1982 • Various Advanced Echocardiography Courses done in Chicago, Cleveland, San Diego, Washington, London and South Africa

18. Recommendations

19. Establishment of an independent body to audit private practice coding, services and utilisation • Medical Schemes/Administrators are the sole role player in disputes • Monopolise data and information generated by the industry, without sharing it with the industry. • The professional organisations do not have access to data to monitor profession or to assist doctors to manage their practice. • Recommendation: an independent body composed of all stakeholders and role players, including practitioners, should be established to draft procedural coding, audit, monitor utilisation, etc. • This independent body will determine the terms of references. The current biased, non-transparent system is open to abusive and discriminatory practices.