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MEDBRIEF AFRICA The inaugural Fraud, Waste and Abuse Summit convened by the Council for Medical Schemes (CMS) ended in Sandton yesterday with several key stakeholders signing an industry charter launched as a collective undertaking to combat fraud, waste and abuse challenges primarily in the private healthcare funding industry. “Fraud, waste and abuse (FWA), as we have heard throughout this summit, is a huge problem threatening the sustainability of both the public and private healthcare systems,” charter steering committee chair, Dr Guni Goolab, warned when announcing the initiative. “What is needed is a national commitment to reduce FWA to improve efficiencies while ensuring transparency across the healthcare system – a key objective of the charter,” he added. Healthcare fraud, he reminded his audience, was “knowingly submitting, or causing to be submitted, false claims or an intentional misrepresentation of the facts in order to access payment of a benefit to which one would otherwise not have been entitled”. “Waste and abuse,” he added, “was claiming for healthcare treatment and services that are not medically necessary, including any form of over-charging of a patient, and that may objectively considered unethical or unconscionable or contrary to best practice principles.” The industry, CMS registrar Dr Sipho Kabane stated when alluding to the extent of the problems in his introductory address, was losing more than R25bn, or approximately 15% of all claims annually due to FWA. “Out of the R172bn annual claims paid out by schemes in 2017, those rejected amounted to R29bn. Therefore, if all claims were paid out, the proportion of FWA would be R30.15bn,” said Kabane. Contributing factors, he reiterated, could be attributed largely to the activities and behaviour of scheme members, service providers, and scheme administrators. Common fraudulent and abusive practices by members, for example, included fake ailments, member substitution and dual membership, service-provider hopping, altered invoices, identity theft and collusion with providers. Common among the unsavoury practices by service providers, Kabane pointed out, were claims for services or goods not provided, false claims and over-billing, falsification of patient information, and miscoding. “What some of them are also doing is supplying non-medical goods and services at the expense of the scheme, admitting patients for non-existent ailments and in some cases receiving kick-backs from hospitals and specialists, creating a supplier-induced demand and colluding with members.” Complaints against administrators centred around mainly the variety of methodologies and systems they use for fraud protection, such as coercing providers to sign an acknowledgement of debt, use of hidden cameras, seizure of patient records, intimidation and disruption of clinical practices, and at worst, the use of sting operations and entrapment of health professionals. Main objective of the charter, Goolab noted – reiterating a point thrashed out throughout the summit proceedings – is to facilitate the collaboration between all stakeholders to combat FWA “with a common understanding and purpose between parties” in the strengthening of measures to prevent and tackle fraud, waste and abuse”. Ultimate objective will be to enhance the integrity, accountability and financial management of medical schemes. The following stakeholders were invited to pledge their commitment to reaching the Charter Objectives: National Department of Health, Council for Medical Schemes (CMS), Healthcare Professions Council of SA, Pharmacy Council of SA, Board of Healthcare Funders, Healthcare Funders Association, schemes registered with the CMS, brokers, managed care organisations and administrators registered with the CMS, law enforcement agencies, and professional societies associations within the sector on behalf of their members. Further details available at http://www.fwasummit.co.za
Created at 2019/03/11 09:03 AM by Mediclinic
Last modified at 2019/03/11 09:05 AM by Mediclinic