• Plants can play a vital role in linking individuals to crime scenes: from the leaves we step on to the pollen that stick to our clothes. If you are curious about the secret language of plants and the link to crime scenes, be sure to read the article about Forensic Botany published in Servamus: September 2020.

  • Forensics is a fascinating science with a variety of subdisciplines that are used to link an individual to a crime scene. In an article published in Servamus: September 2020, we highlight some of the lesser known forensic disciplines.

  • Wildlife crime can be fought by using forensics, such as in poaching incidents where forensics is used to link seized rhino horn or ivory to a crime scene. If you want to read about the development of wildlife forensics, be sure to read the article in Servamus: September 2020.

  • 1
  • 2
  • 3
  • 4
0
0
0
s2smodern
powered by social2s

Blame it on healthcare fraud, abuse and waste

By Kotie Geldenhuys 

We all complain about the high costs of private healthcare and the monthly contributions we have to pay. But the main culprit for these ever-increasing costs, is healthcare fraud, one of the fastest growing crimes in South Africa. Classified as a white-collar crime, healthcare fraud consumes millions of rand from the South African economy each year.

The Council for Medical Schemes (CMS) informs us that compared to other types of insurance, claims in the healthcare sector are much higher and far more frequent, with 90% of policy-holders submitting claims in any given year, compared to 25% in other sectors. With more than 67 000 diagnosis codes and 87 000 procedure codes, healthcare insurance is more complicated. This frequency and complexity open up the system to abuse and waste, whether intentionally or not (Business Tech, 2019).

Healthcare fraud occurs in many different and creative ways. An example is a farmer who also owns an independent pharmacy, selling sheep and claiming the cost from his customers' medical aid schemes. In another case a woman used her medical aid to have her brother admitted to hospital, claiming that he was her husband (Pedersen, 2018). There is no doubt that these are two fraud cases. Healthcare fraud is defined as: “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 you would otherwise not have been entitled.” Intentionally submitting a false claim to receive a benefit, is considered a criminal act in terms of the Medical Schemes Act 131 of 1998 and punishable with incarceration on conviction. In instances where a funder can prove fraud in excess of R100 000 beyond reasonable doubt, they have a legal obligation to report it to the SAPS (CMS, 2019).

 

Abuse and waste of benefits

Apart from fraud, there are also so-called grey areas: waste and abuse, which are not crimes per se, but which cost medical schemes millions of rand every year. A common remark that is often made by medical aid scheme members is that they contribute a lot of money to the healthcare insurer every month, so they can use their available benefits as they want to. There are also those who believe that, when the end of the year comes, they should quickly “stock up” to use the last of their medical scheme benefits for the year. These are examples of waste and abuse of benefits. The CMS explains that the elements of waste and abuse are as harmful as the effect of fraud and that both have a direct impact on other medical scheme members, including the viability of the private healthcare sector and the economy.

According to the CMS, abuse refers to practices that are inconsistent with sound fiscal, business or medical practices and result in an unnecessary cost to a medical scheme, or in reimbursement for services that are not medically necessary. Waste refers to the extra costs incurred when healthcare services are overused, or when bills for services are prepared incorrectly. Unlike fraud, waste is usually caused by mistakes rather than illegal or intentionally wrongful actions (CMS, 2018). In short, waste and abuse refer to “the claiming for healthcare treatment and services that are not absolutely medically necessary, including any form of over-servicing or overcharging of a patient, and that may objectively be considered unethical or unconscionable or contrary to best practice principles” (CMS, 2019).

Paul Midlane, the General Manager of Healthcare Forensics at Medscheme, which administrates 13 medical schemes, including Polmed, told Servamus that over-servicing and overcharging is a big problem. Although the Health Professions Council of South Africa (HPCSA) prohibits over-servicing or overcharging in their ethical rules, a recent Health Market Inquiry (HMI) found that Supplier Induced Demand (SID) and over-servicing significant contributors to escalating healthcare costs (CMS, 2019).

 

Types of fraud, abuse and waste in the healthcare environment

Medical schemes are easy targets for fraudsters, because unlike other forms of insurance, medical aids often pay up front and in good faith when a claim is submitted. This is done to ensure that members have immediate access to healthcare treatment when they need it most (Pedersen, 2019). Lerato Mosiah, the CEO of the Health Funders Association said that some of the most common incidences of fraud, waste and abuse encountered by medical schemes include:

 Member non-disclosure, where members do not disclose pre-existing conditions to the scheme;

  • obtaining sunglasses where prescription spectacles have been claimed for;
  • claiming for fillings when cosmetic dental work has been performed;
  • ordering unnecessary blood tests and scans;
  • pharmacies claiming for medicine but dispensing groceries and other non-medicine items; and
  • kickbacks on referrals (Mosiah, 2018).

The Counsel for Medical Schemes added the following to the fraud list:

  • Members allowing their healthcare provider to charge for services not provided;
  • members lending their medical scheme card to unregistered dependants, such as friends and family members;
  • members providing their medical scheme or policy details to a healthcare provider for the purpose of submitting false claims in order to obtain a percentage of cash for the healthcare provider upon payment of the false claims from the medical scheme or insurer; and
  • members being admitted to hospital 2 for a non-existent ailment in order to benefit from the cash payment from the insurer (CMS, 2018).]

******************************

[This is only an extract of an article published in Servamus: August 2020. The rest of the article focuses on the perpetrator, which include both medical scheme members and healthcare providers and how they do it; the cost of healthcare fraud; dealing with fraud; the role of medical scheme members; hospital cash plans - another opportunity for fraud; and the impact of COVID-19 on healthcare fraud. If you are interested in reading the comprehensive article, send an e-mail to: This email address is being protected from spambots. You need JavaScript enabled to view it.. Contact Servamus’s office at tel: (012) 345 4660/41. Ed.]

0
0
0
s2smodern
powered by social2s

Servamus - September 2020

When crimes are committed, the first thing criminals want to do is to get rid of the evidence that would link them to that crime.
By Kotie Geldenhuys
When Albert du Preez Myburgh abducted, sexually assaulted and murdered his close friend's eight-year-old daughter in May 1999, he did not realise that bugs would play a role in his conviction and sentence.
By Kotie Geldenhuys
When Sinja Robin Mabitsela and Josias Xaniseka Mkansi (also known as the Alexandra Balaclava serial rapists) started their raping spree, they did not realise that their DNA would be their downfall.
By Kotie Geldenhuys
Imagine how challenging it must be for scientists to identify a victim when only skeleton remains are available… now imagine how much bigger this challenge becomes for forensic anthropologists when only burnt skeleton remains are available and they have to identify these bones.
By Kotie Geldenhuys

Pollex - September 2020

In Servamus: July 2020, Pollex published a legal quiz regarding the current/recent state of disaster. Please refer to that issue for the questions.

Letters - September 2020

The current COVID-19 pandemic which has affected many and claimed the lives of so many, is still continuing to be a global threat for which there is no cure.
Const Kwayo Louw (23), a policeman from Kraaifontein, was recently commended by the Western Cape Minister of Community Safety, Albert Fritz for his exemplary contribution towards his community in Kraaifontein.
Retired W/O Sham Singh, the first Indian Station Commander of Lenasia, celebrated his 80th birthday on 9 July 2020. A milestone birthday for anyone and it was even posted on Facebook.
September Magazine Cover

Servamus' Mission

Servamus is a community-based safety and security magazine for both members of the community as well as safety and security practitioners with the aim of increasing knowledge and sharing information, dedicated to improving their expertise, professionalism and service delivery standards. It promotes sound crime management practices, freedom of speech, education, training, information sharing and a networking platform.