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In recent months, we have shared information on the concept of medical aid and key issues surrounding health insurance, that is, shortfalls and co-payments.
We even went further to deliberate on the mandate and operations of one of the country’s largest and oldest medical aid societies, PSMAS.
This week we want to focus on yet another contentious issue in the health insurance industry, that is, claims investigations and quality assurance, also known as fraud, waste and abuse.
We will also look at the implications of fraud, waste and abuse for the member, for the Fund and for other members as well.
In health insurance, claim investigations and quality assurance is key for monitoring and evaluation of the claiming pattern of service providers with the objective of detecting fraudulent and irregular claims, pre-empting possible fraud on claims, and recommending ways of preventing such incidents from happening.
This function is also tasked with reviewing service provider adherence to claiming guidelines from national statutes and the Association of Healthcare Funders of Zimbabwe (AHFoZ) namely;
Medical Services Act
Zimbabwe Relative Value Schedule (ZRVS)
Tariffs for Private Hospitals and Associated Units (TPHAU)
NAMAS Scale of Dental Awards
Ambulance Services Guidelines
Policies and Adjudication Guidelines
The ultimate goal for these objectives is to curb fraud, waste and abuse of the medical aid Fund. For the benefit of those who missed our earlier sessions, the three terms are defined as follows:
Fraud
It occurs when a healthcare provider or member deceives an insurer/funder in order to receive greater reimbursement.
Waste
This is when a member overuses health services carelessly
Abuse
It happens when best medical practices are not followed, leading to costs and treatments that aren’t needed
Examples of anomalies that constitute fraud, waste and abuse
- Medical aid card fraud
Card fraud is when a registered member intentionally gives his/her membership card to a non-registered member so that he/she can use the card to receive service from a medical practitioner.
This is usually between friends and relatives. This can be done individually by the member or in connivance with the service provider.
- Member connivance with the service provider.
Member and service providers can also connive to defraud the fund by agreeing to sign a medical aid claim form when service has not been rendered and they share the proceeds.
- Over-servicing
Over servicing by a member includes unnecessary visits by a member to service providers.
It also includes visiting emergency rooms or 24-hour units with minor ailments like flu, and unnecessary tests and procedures. A member is expected to visit low cost service providers like clinics and general practitioners if they have minor ailments.
Abuse of medical aid is much easier if the regulations surrounding it are lax.
That is why it is important for medical aid companies to have clear rules that best match medical aid contribution costs and the benefit.
This will result in less temptation to overuse useless procedures that might make some service providers rich but do nothing and perhaps even harm the member.
In view of this, we want to look at the issue of over-servicing by the member.
Over-servicing can be done by service providers.
This happens when a medical practitioner provides medical services or makes medical recommendations that are unreasonably required, or considered excessive. Unnecessary tests, procedures and care are the most popular form of over-servicing in Zimbabwe.
This abuse, where best medical practices are not followed, leads to costs and treatments that aren’t needed, over servicing by service providers is an example of abuse and includes but not limited to;
Frequent reviews for minor ailments.
Requesting for blood tests that do not tally with illness for example FBC for flu.
Family treatments where one member visits the Doctor with a condition like flu or diarrhoea and the Doctor decides to treat the whole family before they are sick.
Self-referrals if the Doctor is also running other units like radiology or laboratory.
(Group facilities)
Monthly consultations for patients on chronic drugs when they ask the patient to visit every month for prescription purposes.
Over and above over-servicing, service providers can also:
Claim for services not rendered
Duplicate claiming for example consultation at room and hospital on the same day by specialists
Unbundling of tariffs by Specialists and Laboratories
Duplicate claiming using different tariffs or claiming the same surgical procedure using different dates.
Claiming for drugs not dispensed by pharmacies
Under or over dispensing which is not in line with the prescriptions by Pharmacies
Substitution of drug with an expensive one by pharmacies
Addition of tests above what the Doctor has requested by Laboratories
Claiming for emergency tariffs where the diagnosis is not emergency
Claiming of non-payables by Hospitals.
Transfers to hospitals with no record of consultation at the receiving hospital by ambulances
Implications to the Member and to the Fund
The implication of the above anomalies is the depletion of the members’ limits/benefits by the service providers at their advantage and financial losses to the fund thereby threatening its viability.
Emergency rooms and 24-hour units are considered hospitals and visiting them with minor ailments will deplete a member’s hospital benefits, which will be needed in real emergency cases like accidents and hospitalisation.
This is the reason why health insurance companies like PSMAS, ask for pre-authorisations and quote system.
This allows us to ensure that necessary benefits are available on the member’s plan, and to be up-front about costs which will not be covered and why.
PSMAS also makes use of managed care and co-ordinated care strategies.
Managed care is basically a holistic approach to healthcare, which ensures the cost-effective and appropriate use of resources. As part of the managed healthcare strategy, doctors, specialists and case managers work together to decide on the most cost-effective treatment for the patient.
Co-ordinated care further manages costs by requiring GP referrals and authorisation for hospitalisation and procedures that will be paid from insured benefits.
Online Reporter