R22bn medical aid rip-off

Corrupt doctors, pharmacists, physiotherapists, radiologists and pathologists are ripping off medical aids to the tune of R22-billion a year - resulting in members having to fork out thousands of rands more in premiums.

The alarming increase in fraud has become a nightmare for almost 100 medical aid schemes and prompted the Board of Healthcare Funders, which represents medical aids, to convene a two-day conference in Johannesburg to deal with the problem.

On the first day of the conference yesterday, medical aid investigators detailed some of the brazen tactics employed by medical professionals.

In one instance, the Polmed scheme caught out a physiotherapist who billed for 93 appointments in one day. She billed another scheme for more than 100 appointments on the same day.

A doctor billed a scheme for 107 appointments in a day, each taking two hours, which would have meant he worked 214 hours in one day.

In some cases doctors supposedly treated patients in Durban, Bloemfontein and Pretoria on the same day.

The international head of information analysis com-pany SAS, Chris McAuley, said the company had analysed almost two-and-a-half years of medical aid data.

It estimated that each member of a medical scheme in South Africa was effectively paying between R2500 and R2800 a year to cover fraudulent and irregular expenditure.

The figure of R22-billion in fraud was "not a thumb-suck" but based on the analysis of medical aid data, he said.

Polmed medical scheme investigator Jaco Makkink said some doctors billed three times for one procedure, hiding behind complicated billing codes, or colluding with patients to bill for appointments that did not take place.

There were even cases of men claiming for hysterectomies or women for a circumcision.

"Incorrect gender claims are made, it happens, and some claims are even paid," said Makkink.

He complained that anti-competitive legislation prevented medical schemes from sharing information that might stop collusion. This made it easier for healthcare providers to claim for an excessive number of appointments and to multiple medical schemes.

There was general agreement that "the vast majority of clinical practitioners are ethical. It is only a minority killing the system".

Common methods used to defraud medical aid schemes include:

• Instead of using one billing code for a procedure, such as surgery on a shoulder, doctors bill for multiple procedures, using one code for cutting into the shoulder and another for operating on the shoulder muscles - the latter billed as an additional procedure though covered by the first code;
• A radiology practice in Gauteng billed medical schemes for disposable gowns for every patient, irrespective of whether the patients needed a gown. They bought them for R16 and sold them for more than R100 a patient. One small scheme paid out R10000 a month for disposable gowns;
• Patients are sent for unnecessary blood tests, scans and other diagnostic procedures. However, this can be done to protect a doctor from being sued for negligence; and
• Short-term insurance schemes that pay cash for every day spent in hospital are abused by doctors, hospitals and patients who work in cahoots to admit patients who do not need hospital in-patient treatment.

But schemes use sophisticated analysis and technology to catch fraudsters.

Fiona van Zyl, managing director of Ingelozi Aurora Data Services, said analysis would pick up doctors who administered a high ratio of similar tests to many patients.

She said a new trend was for blacklisted doctors to collude in finding other healthcare providers to continue colluding with in their name.