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NC medical fraud probed


Of the 5 443 cases that were reported for possible irregularities, concerns were confirmed on approximately 75% of investigations

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DISCOVERY Health last year investigated 33 cases of fraud, waste and abuse in the Northern Cape.

According to the financial services organisation, a total of
R555 million was recovered throughout the country following the company’s efforts to curb fraud, waste and abuse in the health care system.

“We also estimate that the ‘halo’ effect of our extensive fraud, waste and abuse-control activities has prevented additional fraud, waste and abuse to the value of approximately
R5.1 billion in the past couple of years,” Discovery Health CEO, Dr Jonathan Broomberg, stated.

Efforts to fight the scourge of health care fraud, waste and abuse by the company included the deployment of a specialised team of over 100 analysts and professional investigators as well as a proprietary forensic software system that uses continually updated algorithms to analyse claims data and identify any unusual claim patterns.

“Invaluable tip-offs from whistle-blowers also helped to identify fraud, waste and abuse.”

Of the 5 443 cases that were reported for possible irregularities, concerns were confirmed on approximately 75% of investigations.

The least number of fraud, waste and abuse cases investigated in 2018 emanated from the Northern Cape (33 – down from 52 in 2017).

Broomberg pointed out that the vast majority of health care providers were honest, hard-working, highly ethical professionals who delivered diligent care to their patients. “However, forensic investigations reveal that a minority of health care professionals committed fraud against medical schemes, resulting in significant costs to schemes and their members,” Broomberg added.

Types of fraud, waste and abuse cases identified in 2018 included claims submitted for services not rendered (40%); capturing errors by a practice (16%); procedural codes applied incorrectly by health care providers – e.g. using a code that carries a higher value than the service performed (12%); outlier trends are identified for a practice – an audit is needed to verify claims (11%); duplication of claims (6%); claims by non-members (4%); and claims for more expensive items or items different to those supplied (4%).

Examples of fraud, waste and abuse committed in 2018 included sharing patient records for profit.

“When a registered nurse’s income jumped from R10 000 to R500 000 per month analysis revealed a spike in claims related to a very expensive intravenous feeding product – carried out at a hospital far from the nurse’s registered address. The registered nurse was unknown to this hospital. He admitted that a nursing sister employed at the hospital in question had shared patient information with him to facilitate the fraudulent claims under the registered nurse’s practice number. They shared the proceeds. The registered nurse was dismissed. A criminal case has been registered against both individuals for fraud in excess of R3 million.”- Staff Reporter