Dr. Lydia Dsane-Selby Director, Claims National Health Insurance Authority, Ghana

1. Effective methods of preventing and mitigating medical scheme abuse 2013 GEMS Annual Symposium Protecting GEMS value against benefit abuse Dr. Lydia Dsane-Selby Director, Claims National Health Insurance Authority, Ghana 15th August, 2013

2. Outline of Presentation Definition Motivators Types of fraud and abuse Prevention/Mitigation methods The way forward

3. Definition • ABUSE: The use of something in a way that is wrong or harmful. (Oxford Advanced Learner’s Dictionary) • FRAUD: The crime of deceiving somebody in order to get money or goods illegally. (Oxford Advanced Learner’s Dictionary)

4. Definition HEALTH INSURANCE FRAUD • Health insurance fraud is described as an intentional act of deceiving, concealing, or misrepresenting information that results in health care benefits being paid to an individual or group. • Fraud can be committed by both a member and a provider.

5. Motivators - Providers • Wide range of potential medical conditions and treatments to choose from • Ability to spread false billings among many insurers • Fidelity to patients • Exploitation of loopholes in the provider payment system • Inadequate fraud prevention and detection amongst insurers

6. Motivators - Members • Misconceptions about insurance – victimless crime, insurers have lots of money • Mutually beneficial to parties involved • Exploitation of loopholes • Financial gain • Limited legal deterrents or sanctions

7. Areas of fraud Source: Google Images

8. Types of fraud/abuse - Providers • Billing for services not rendered • Up-coding of services • Double billing/Duplicate claims • Misrepresentation of diagnosis • Unbundling of services • Unnecessary services • Inappropriate referral for financial gain • Insertion/Substitution of medicines • Unauthorised co-payments • Limited sanctions and legal deterrents against public sector facilities

9. Types of fraud/abuse - Members • Impersonation – a non-member using a member’s identity • Ganging – all the family using one member’s card • Provider shopping • Illegal cash exchange for prescriptions • Frivolous use of services – drugs for sale

10. Types of fraud/abuse - Insurer • Tampering with eligibility dates – fast tracking to avoid waiting period • Incomplete vetting of claims – claims that should be adjudicated downwards are allowed to pass • Collusion with providers – staff colluding with a provider to inflate claims and take a kickback

11. Ways to prevent/mitigate abuse • Policy methods – • Payment mechanisms - Each payment method has its advantages in tackling certain types of abuse • Good ICT – electronic claims submission and vetting • Robust membership authentication - registration and point of service • Sensitisation of members – on impact of fraud and abuse • Pre-payment methods – effective claims processing • Membership • Treatment protocols • Electronic vetting business rules • Statement of benefit – members can verify the claims submitted on their behalf • Post-payment methods • Data analysis • Clinical Audit & claims verification • Good investigation and prosecution capacity

12. Policy Methods Provider Payment Mechanisms • Capitation –control unnecessary services, duplicate claims, membership fraud and abuse. may lead to underservicing, unauthorised co-payments • DRG – control over billing, over servicing, unnecessary services, non-adherence to treatment protocols may lead to unbundling, up-coding of the tariffs • Fee for service – control underservicing, may lead to oversupply, insertions of medicines, substitution of medicines Benefit Package • Explicit inclusion list • Specific exclusion list • Reimbursable medicines list

13. Policy Methods ICT • Nationwide database of members and providers • Membership authentication at provider sites - biometric • Electronic claims submission with a claims check code Sensitisation of general public • Types of fraud • National impact of fraud • Financial implications for the sustainability of the scheme • Health implications of fraud and abuse for members

14. Claims Processing Provider Payment Eligibility & Membership E-Vetting & E-Adjudication Paper Claims Treatment Codes G-DRG ICD-10 E-Claims Statistical Data Process, Business Rules Based Engine !! 22

15. Pre-Payment Methods Claims management – Electronic & Manual Biometric authentication at provider site – eligibility & membership – generate claims check code Member unique ID number checked against membership database when claims submitted Alert for any claims using the same unique ID number within the last month at any provider Check appropriateness of diagnosis against age and gender Check match between diagnosis and treatment Check that agreed tariffs for medicines and services have been used

16. Comparing Claims Adjustments at CPC to Nationwide (2011)

17. Post-Payment Methods Data Analysis Top 20 in-patient DRG’s for each specialty Top 50 medicines diagnosed – by volume and by value Service utilisation – OPD and IPD Cost per claim for different provider types Monthly value of claims per provider type per district Month on month value of claims for each provider

18. Post-Payment Methods Claims verification & Clinical Audit Verify the attendance at the provider site Verify the services given Verify the medicines prescribed and dispensed Contact members to confirm attendance, services & medicines given Assess the quality of care

19. Post-Payment Methods Develop Investigation & Prosecution capacity Good and accurate documentation Evidence gathering Knowledge of the appropriate laws Education of police and prosecutors on medical fraud Special medical fraud prosecution unit

20. KEY FINDINGS Cost retrieval

21. The Way forward Incentives Whistleblowers Encourage whistleblowers and protect them by legislation Clean claims Early reimbursement for providers with clean claims. % tariff increase for adherence to treatment protocols % tariff increase Training of health insurance staff in fradu detection Advocacy on impact Increased advocacy and sensitisation on the impact of fraud and abuse on the health insurance system

22. The Way forward Deterrents Legislation Pass specific health insurance fraud laws making it a criminal offence e.g. USA Health Insurance Portability and Accountability of 1996 (HIPAA) Financial penalties Financial penalties above repayment of fraudulent payments Disaccreditation/ loss of license Health care provider should lose its license with the regulatory bodies as well as disaccreditation by the insurer Name and Shame Public gazetting of fraud and abuse cases

23. CONCLUSION • Health Insurance fraud is a global phenomenon • It cannot be eliminated entirely but can be minimised • Methods to prevent fraud is insurance scheme and country specific although there are general measures that can apply to all • There will always be loopholes in the medical scheme. • Each time a loophole is closed, another is found. • Insurers need to work with providers and members if the prevention methods are to be successful.

24. Thank You Dankie Ngiyabonga