SPONSORED: GEMS_Number1 has grown to cover more than 760 000 public service employees working across various government departments and over two million beneficiaries. Taking a zero-tolerance stance to fraud, waste and abuse, Dr Stan Moloabi says;
) Dr Stan Moloabi and his team have been tasked with. The problem is that the sustainability of delivering on these objectives becomes increasingly difficult amid rising costs and the negative effects of fraud, waste and abuse in the healthcare sector.
“A member approaches a healthcare provider or healthcare institution that then provides a service or medical intervention, and submits the claim to the medical scheme, which acts as a third party payer,” he explains. “There are minimum requirements for how claims are processed and validated. The scheme, as a third party payer, does not see the services offered first-hand; payment is made because there is an element of trust involved — with our members and also the service providers in question.
“This also has an important impact on healthcare providers and healthcare facilities, because we are faced with a situation where all healthcare providers may be painted as being involved in fraud, and the system of trust is eroded,” he says. “This is tragic, because only a small percentage of providers are involved in fraud, waste and abuse. Unfortunately, the entire industry is painted with the same bad brush.
At the end of the day, he says, as a medical scheme must be run as a business, albeit a not-for-profit business: “And the core objective of this business is to always act in the best interest of its members. They have put their trust in us as officers of to protect their money and ensure it will be available when they become sick or injured.”
The Claims Management Forum that was implemented in the same year has contributed to the significant and consistent growth of the scheme’s reserve ratio. Risk mitigation measures such as early warning reporting and underwriting have lowered the impact of fraud, waste and abuse and succeeded in rerouting funds that would have been lost to improve the lives of beneficiaries during their darkest hours.
also identified pharmacies that claimed exclusively for high-cost medications while providing patients with cheap generics, while another pharmacy syndicate was uncovered that was submitting excessive claims for members, some of whom lived hundreds of kilometres away.
In serious cases though, perpetrators must be brought to book. Medical schemes do not have the jurisdiction to discipline, fine or prosecute health practitioners, but they can report them to the police or to statutory and regulatory bodies for further action. Should the investigations find sufficient evidence of criminal action, the case is then referred to law enforcement authorities for criminal prosecution, or to the courts for civil action.
The direct consequences of fraud include, but are not limited to: direct financial losses to the members of the scheme, the cost of investigations, legal costs and reputational damage, both to individuals and the healthcare sector at large. Money spent on fraud, waste and abuse in the healthcare sector means there is less money available to cover legitimate medical expenses.
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