{"id":1138,"date":"2017-03-28T10:24:40","date_gmt":"2017-03-28T08:24:40","guid":{"rendered":"https:\/\/www.namfisa.com.na\/educates\/?post_type=did_you_know&p=1138"},"modified":"2025-07-19T15:32:31","modified_gmt":"2025-07-19T13:32:31","slug":"healthcare-fraud-abuse-and-waste-2","status":"publish","type":"post","link":"https:\/\/www.namfisa.com.na\/educates\/healthcare-fraud-abuse-and-waste-2\/","title":{"rendered":"Healthcare Fraud, Abuse And Waste"},"content":{"rendered":"\t\t
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Preventing Healthcare Fraud, Abuse, and Waste: A Shared Responsibility<\/h3><\/span><\/div>
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\u201cDO NOT sign your name on a blank form. Ask for a copy of everything you sign. Keep the copy for your records.\u201d<\/div><\/div>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t
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Waste refers to inefficient or unnecessary services. A common example includes the unbundling of procedures\u2014charging separately for services that should be billed together at a reduced rate.<\/div><\/div>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t
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Abuse includes excessive or unreasonable billing practices, such as upcoding (billing for more expensive services than were provided), or charging for services that are not medically necessary.<\/div><\/div>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t
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Fraud is a deliberate attempt to deceive. This includes falsifying claims, billing for services never rendered, or using someone else\u2019s medical aid card. Fraud is the most severe form of misconduct on this continuum.<\/div><\/div>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t
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Tips to Protect Yourself<\/h3><\/span><\/div>
\u2022 DO NOT sign your name on a blank form. Ask for a copy of everything you sign. Keep the copy for your records.
\n\u2022 Count your pills each time you pick up a prescription.
\n\u2022 Research your healthcare providers with the respective healthcare professional boards.
\n\u2022 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.

\n\u2013 Article continues from 2014 Christmas Bulletin

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Understanding Healthcare Fraud, Abuse, and Waste<\/h3><\/span><\/div>
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.\n
\nHealthcare 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\u2019s fraud, which is an aberrant behaviour, aimed at deceiving Medical Aid Funds, amongst all other affected parties.\n
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What You Can Do to Prevent Healthcare Fraud?<\/h3><\/span><\/div>
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:

\n\n\u2022 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.
\n\u2022 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.
\n\u2022 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.
\n\u2022 DO NOT let anyone borrow your medical aid card. Treat your card the way you treat your bank\/ credit card.
\n\u2022 DO NOT share your medical records or other medical information with anyone except your doctor, clinic, hospital or other healthcare provider.
\n\u2022 DO NOT accept free tests or screenings in exchange for your medical aid card number \u2014 be suspicious. Be careful about accepting medical services when you are told they will be free of charge.
\n\u2022 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.
\n\u2022 DO NOT ask your doctor or other healthcare provider for medical care that you do not need.

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Why Healthcare Fraud Matters<\/h3><\/span><\/div>
Healthcare fraud, abuse and waste is a serious problem that affects everyone and should concern everyone \u2014 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.

\n\nOften 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 \u2014 before payment.

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References<\/h3><\/span><\/div>
Ethics CPD supplement: Ethics in healthcare: Healthcare Fraud 2014:56:1:1: S10 \u2013 S13 Official journal of South African Family Physicians S Afr Fam Pract: ISSN (Print): 2078-6190, ISSN (Web): 2078-6204
\n\nThe real cost of healthcare fraud and new ways to fight it. www.lexisnexis.com\/risk\/healthcare
\n\nNational 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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