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01 Jan 2002 00:00
AT LEAST 40c out of every rand reimbursed by medical aid societies is paid out on fraudulent medical aid claims. And the biggest culprits are doctors, dentists and other respected members of the health-care sector.
Now medical aid companies have declared war on medical practitioners who submit fraudulent claims.
“We have adopted a policy of zero tolerance for offenders,” says the CEO of Allcare, Howard Phillips.
“The biggest casualties of these crimes are the public who are being forced to pay higher premiums to cover losses due to medical aid fraud.”
Allcare is not the only medical aid to take a hard line on offending medi-cal practitioners.
The Board of Healthcare Funders (BHF), which represents the medical schemes, estimates South Africans pay about R8-billion a year in medical costs because of fraud, corruption and perverse incentives perpetrated by corrupt hospitals, pathologists, doctors and dentists.
But the BHF admits that it, like the Department of Health and police services, lacks the capacity to investigate every fraudulent claim. It is therefore up to medical aid companies to track down offenders.
To this end companies such as Medscheme and Allcare have employed specialised private investigators experienced in commercial crimes.
“Most medical aids have internal departments to investigate fraudulent claims, but the workload is too much,” says a private investigator whose company, Stallion Investigations, is working for Allcare.
He says that in the past month there has been progress in cleaning up the industry.
Last week a dentist was arrested. He appeared in the Randburg court on charges of fraud and was released on R10 000 bail and the hearing was postponed.
The investigator says that the steep bail indicates how seriously courts are starting to take medical aid fraud.
In the case involving the dentist, Allcare alleges that for last December alone, false claims of about R40 000 had allegedly been sent to Allcare. Yet the dentist had allegedly absconded from his practice in Soweto several months before the claims were issued.
Allcare alleges that several of its members have sworn in affidavits that they had never consulted the dentist.
Allcare has also been told by its investigator that another medical practitioner allegedly absconded from his practice in Soweto. He allegedly sent Allcare claims from two practice addresses one of which was found to be non-existent.
The private investigator says the dentist allegedly disappeared in February last year. In December medical claims were still arriving at Allcare. A warrant has been issued for his arrest.
Some of the cases being investigated involve collusion between patients and doctors, with patients offered a portion of the doctor’s claim.
In other cases, a medical practitioner had been dispensing psychiatric medication without proper authorisation to a group of patients who - judging by the claim forms - all suffer from the identical mental ailment; doctors have been profiting so handsomely from fraudulent claims they have started moonlighting as money lenders; during visits to 1 103 dispensing doctors in 1996, medical inspectors found medicines incorrectly labelled and stored in unsafe, unhygienic facilities; they uncovered instances where doctors had provided patients with placebo pills, over-the-counter medication or generics disguised as expensive prescription drugs; and patients with simple ailments had been prescribed schedule seven drugs. The doctors would then send in claim forms for the costly prescription drugs.
Medical aid companies say that corruption is rife in both affluent and disadvantaged areas.
But it seems that abuse of the system is particularly problematic in remote rural areas where impoverished patients often fall victim to allegedly dishonest dispensing doctors.
But Allcare also has in its possession claim forms from doctors in affluent areas who have prescribed drugs such as the anti-depressant Prozac and Rohypnol sleeping pills without the obligatory consultation. These doctors have claimed both medication and consultation fees.
Indirect abuse is just as harmful to South Africa’s health-care system and includes alleged over-servicing by doctors, for example, providing unnecessary treatment.
The BHF says some doctors also accept commissions or financial incentives in return for the purchase, sale or supply of medication. This can lead to dispensing doctors over-prescribing.
Abuse is allegedly rife among pharmaceutical companies and pathology laboratories demanding kickbacks.
But medical aid companies say employees in some hospitals are the biggest offenders and difficult to bust.
“At one hospital people in the accounts department can earn R2 000 cash a week bonus if they double the bills of patients leaving hospital,” says a doctor who has requested anonymity.
“Often patients don’t bother to properly check their accounts, so the hospital gets away with it.”
This was not the case with a hospital in Kwazulu-Natal. It sent a hefty account to a patient for heart bypass surgery. The procedure usually takes three to four hours. The hospital billed the patient for 10 hours.
It was only after a vigilant medical consultant at the medical aid checked the anaesthetist’s records that it was discovered the operation had taken three hours.
The “accounting glitch” resulted in the hospital reimbursing the medical aid R12 524.
He says: “The problem is that the public lands up paying the price.
“We would be able to lower our premiums substantially if we succeed in cleaning up the industry,” says Phillips.
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