HEALTHCARE FRAUD, ABUSE AND WASTE

• DO NOT sign your name on a blank form. Ask for a copy of everything you sign. Keep the copy for your records.

• Count your pills each time you pick up a prescription.

• Research your healthcare providers with the respective healthcare professional boards.

• Report suspected fraud and abuse as soon as possible. Call your medical aid fund immediately if you suspect you may be a victim of healthcare fraud, abuse or waste.

– Article continues from 2014 Christmas Bulletin

Healthcare fraud, abuse and waste exists on a continuum. This continuum helps illustrate the level of intent to deceive a medical service provider or medical aid fund member. Figure 1 depicts the healthcare fraud, abuse and waste continuum. Beginning on the left, is waste. Examples of waste include the unbundling of procedures by healthcare providers.

Healthcare providers may overbill by unbundling medical procedures and charges that should be billed together at a lower rate. In the middle of the continuum is abuse, which is identified with behaviours such as the upcoding of procedures and claims for services that are not reasonable and necessary. Finally, there’s fraud, which is an aberrant behaviour, aimed at deceiving Medical Aid Funds, amongst all other affected parties.

WHAT YOU CAN DO TO PREVENT

HEALTHCARE FRAUD?

Healthcare fraud, abuse and waste is a national problem, and your assistance is vital in helping to prevent it. Simple tips that may help you prevent fraud, abuse and waste include:

• Read and review your benefit claim statements to ensure accurate dates of services, name of

providers, and types of services reported. Make sure you actually received the treatment for which your medical aid fund was charged and question suspicious expenses.

• Be informed. Be informed about the healthcare service you receive, keep records of your medical care and closely review all the medical bills you receive.

• Protect your medical aid card and personal information at all times. DO NOT give your medical aid card number to anyone except your doctor, clinic, hospital or other healthcare provider.

• DO NOT let anyone borrow your medical aid card. Treat your card the way you treat your bank/ credit card.
• DO NOT share your medical records or other medical information with anyone except your doctor, clinic, hospital or other healthcare provider.

• DO NOT accept free tests or screenings in exchange for your medical aid card number- be suspicious. Be careful about accepting medical services when you are told they will be free of charge.

• DO NOT provide your information to anyone who claims they know how to make your medical aid fund pay for healthcare services or goods that are usually not paid for. Avoid conversations with these individuals.

• DO NOT ask your doctor or other healthcare provider for medical care that you do not need.

Healthcare fraud, abuse and waste is a serious problem that affects everyone and should concern everyone – it is a costly reality that none of us can afford to overlook. As the money spent on healthcare continues to rise, the impact of healthcare fraud, abuse and waste is only going to grow. Reducing healthcare fraud, abuse and waste will lead to lower costs throughout the healthcare system and help avoid serious problems for patients.

Often if a claim is paid, it is too late for the medical aid fund to recover losses. It is also difficult for the affected patients to get everything straightened out on their end. It is all the fraud, abuse and waste that is undetected that has the most serious impact. The only real way to prevent a fraudulent act is to stop it in its tracks – before payment.

References:

1. Ethics CPD supplement: Ethics in healthcare:

Healthcare Fraud 2014:56:1:1: S10 – S13 Official journal of South African Family Physicians S Afr Fam Pract: ISSN (Print): 2078-6190, ISSN (Web): 2078-6204

2. The real cost of healthcare fraud and new ways to

fight it. www.lexisnexis.com/risk/healthcare

3. National Healthcare Anti -Fraud Association http://www.nhcaa.org/resources/health-care-anti-fraud-resources/the-challenge-of-health-care-fraud.aspx

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