Slindile Khanyile: Business Report,
TEN of the country's 90 private healthcare brain specialists claimed more than 40 percent of the medical aid money spent on neurology even though they had seen fewer than 25 percent of the patients, sparking an investigation by the Board of Healthcare Funders (BHF). The investigation into the neurologists' billing and coding practices was started after data taken from 11 medical aid schemes showed that the 10 specialists had claimed more than R20 million of the almost R50 million the schemes had spent on neurology in 2006 and last year.
The board's spokesperson, Heidi Kruger, said these cases were being forwarded to the Health Professions Council of South Africa (HPCSA) for further investigation. Kruger said seven of the 10 neurologists were using specific codes which accounted for more than 60 percent of total utilisation. She said 83 percent of these doctors' income was from procedures where the industry average on procedure-based income was 69 percent to 70 percent. One of them made as much as 91 percent of his income from procedures. Kruger said that there was some kind of anomaly, but without further investigation she could not say, at this point, that fraud was involved.
The BHF came across these claims when it started a profiling programme aimed at establishing the average number of patients that doctors attended to depending on the area where the practice was located. This was one of the preventative measures that the BHF embarked on in its effort to curb fraud. Over the past three years, 4 500 people - most of whom were service providers - had been investigated for fraud. These names appeared on the list within the credit bureau which the BHF had established with members of the forensic management unit. The unit was formed in 2004 when BHF realised that there was at least R6 billion to R12 billion that the schemes lost though wastage or fraud. Kruger said that 90 percent of the schemes were members of the unit and the list helped to alert everyone in the industry about fraudsters or possible fraudsters because everyone who was part of the unit had access to it. The unit has helped schemes to recover money. Nine had recovered R133 million in 2006 and 2007. Kruger said it was a minority of service providers who were involved in these activities. Types of fraud ranged from using medical aid money to buy groceries, pots, leather jackets, meat, claiming for non-covered items like gold teeth and claiming for non-covered members. In 2006, the HPCSA investigated 14 doctors who had claimed for services not rendered. Four of these doctors were struck off the roll while the rest were either fined or received various penalties including suspended sentences. Tendai Dhliwayo, spokesperson for the HPCSA, said every month it received more than 100 complaints against healthcare practitioners. He added that at least a case or two of stealing from medical aids was investigated by the legal division. Kruger said the process of criminal justice was slow because the medical aid industry was complex. There was a loophole in the claiming system which made it easier for the service providers to claim more than they should and for services they had not provided. She said members were motivated to defraud medical aids because of the perception that they were cash cows and because people begrudged having to pay what they considered to be high premiums.
