Tag: fraud

Categories : Ethics and LawTags :

Collaboration Needed to Reduce Billions Lost Annually in Healthcare Fraud, Waste and Abuse

On By ModernMedia
Photo by Jp Valery on Unsplash

In an age where healthcare integrity is of the utmost importance, a coalition of industry pioneers and technological trailblazers must lead the charge in driving transformation to combat fraud, waste and abuse (FWA) in the healthcare sector.

As a focal point of discussion on day two of the 2024 BHF Annual Conference, Vusi Makanda, HFMU Deputy Chairperson, and Manager of Fraud Management at Bonitas, set the stage for an interactive discussion on these healthcare issues. 

“Collaboration is paramount in addressing the challenges of healthcare FWA, evidenced by the erosion of trust and substantial financial losses highlighting the call for collective action,” says Makanda.  

Dr Hleli Nhlapo, MD of the medical schemes division at Dental Information Systems (DENIS), echoed Makanda’s sentiments. To this end, Nhlapo set the scene on the current state of FWA in the healthcare industry, suggesting that it exerts unnecessary pressure on resources while undermining trust between stakeholders. 

“Perpetrators are employing increasingly sophisticated tactics, leveraging technology and syndicates to orchestrate large-scale schemes, while regulatory delays and prosecutorial challenges hinder effective resolution,” says Nhlapo. “Despite this, collaboration among healthcare funders has emerged as a crucial solution, with recent initiatives indicating a promising shift towards industry-wide cooperation in addressing these complex challenges.”

Following Nhlapo’s address, Roxane Ferreira, Head of Department at the Association of Certified Fraud Examiners (ACFE), alluded to several global trends in FWA that are plaguing the global industry.

The impact of these is extensive and has led to concerning financial situations for healthcare systems around the world. So much so that Ferreira’s insights suggest that in the United States, it is estimated that as much as $68 billion is lost every year on the back of FWA. 

“In South Africa, the problem is not much better, with between R8 billion and R13 billion being lost annually to this. With between 15-35% of all claims submitted regarded as being fraudulent or abusive, the plight is adding approximately R22 billion to the cost of private healthcare,” adds Ferreira.  

Healthcare fraud is perpetrated by a variety of actors within the system, ranging from medical scheme staff to service providers and even syndicates. These perpetrators exploit vulnerabilities at different points in the healthcare process, whether through falsifying claims, overbilling or engaging in other deceptive practices.

Moreover, medical scheme members themselves, as well as patients, may also be complicit in fraudulent activities, while brokers and manufacturers can also play a role in facilitating these plans. 

Ferreira highlighted the multifaceted approach employed in identifying healthcare fraud, citing that 70% of cases stem from tip-offs or received information, while the remaining 30% are uncovered through data mining, audits and investigations.

“Healthcare fraud encompasses various deceptive practices,” suggests Ferreira. “ Some of the most common ones include merchandising, where pharmacies sell non-healthcare merchandise, but claim for a healthcare service; false claims by claiming for services rendered; ATM scams where doctors submit false claims and provide cash to patients; card farming where members lend their membership cards to non-members; code gaming that involves doctors manipulating billing rules to increase revenue; and lastly, the hospital cash plan fraud that entails doctors and members colluding to arrange unnecessary hospital admissions.”

In response to the escalating challenges of healthcare fraud, Ferreira adds that the sector is increasingly turning to innovative solutions, with the integration of Artificial Intelligence (AI) emerging as a pivotal strategy.

“AI technology offers the capability to analyse large volumes of data rapidly and accurately, enabling the identification of suspicious patterns and behaviours,” she says. “By leveraging AI algorithms, healthcare providers can proactively identify questionable activities, thereby safeguarding resources and maintaining the integrity of healthcare systems”

Using these advanced algorithms, AI can swiftly identify irregularities, such as sudden spikes in billed procedures and visit rates. Furthermore, it can compare billing practices, verify purchases, compare the geographical location of a patient against the practice, and treatments billed for the same or similar treatment by other practices.

In the fight against healthcare FWA, collaboration and technological innovation are emerging as critical pillars. By harnessing advancements such as AI, healthcare systems can effectively detect and prevent fraudulent activities, thus safeguarding resources, upholding the integrity of patient care and rebuilding trust. 

Categories : Ethics and LawTags :

HPCSA’s Nationwide Crackdown on Bogus Doctors Continues

On By ModernMedia
Photo by Bill Oxford on Unsplash

The Health Professions Council of SA (HPCSA) has caught out another individual impersonating a doctor. Mr Tshifata Katembwe, a Congolese national, was practising illegally in Kuruman, Northern Cape while not being accredited with the Council, said spokesperson Christopher Tsatsawane.

According to IOL, since January 2022. Mr Katembwe had been working at a medical practice registered under the name of Dr TK Gopane. This was in in contravention of Section 17(1) of the Health Professions Act, 56 of 1974, said Tsatsawane.

The nationwide crackdown on health-care practitioners operating illegally is gaining momentum with arrests made around the country, Health Professions Council of SA (HPCSA) has noted.

Katembwe appeared before the Kuruman Magistrate’s Court last week, and his case was postponed. Meanwhile, Dr Gopane, registered with HPCSA as a medical practitioner, is to be reported to the Medical and Dental Professions Board for appointing an unregistered person and putting unsuspecting members of the public at risk.

In a separate incident, HPCSA announced the arrest of Mr Simba Koromani, an undocumented Zimbabwean national who applied to practise by using the credentials of Dr Lesne Pucjlowski. The doctor notified the HPCSA that someone had tried to apply for a job with her credentials, which led the Council to collaborate with police in tracking down and arresting the fraudster.

Source: IOL

Categories : Expert Opinion Medical IndustryTags :

Act Now to Stop the Bleed on Medical Schemes Industry

On By ModernMedia

By Junior Biola

Last year, fraud and abuse of medical aids resulted in a loss of R22 billion for medical scheme funds according to The Board of Healthcare Funders – a loss which could be avoided with the implementation of fraud mitigation services.

Medical aid fraud is certainly nothing new: for years, medical schemes have railed against members collaborating with medical practitioners – from doctors to pharmacists – for personal gain. There are the members who convince practitioners to admit them to hospital, for example, and pocket the monies received from their hospital cash back plans; the pharmacists who bill their customers for ‘medicine’, when their baskets are in fact filled with non-medicinal items; or even the practitioners who bill patients for treatments which never take place.

Since the advent of the Covid pandemic, such activities have escalated. In fact, it is no longer rogue pharmacists or practitioners taking advantage of medical aids; the industry is now affected by dishonest members and criminals using stolen cards to deplete medical savings accounts or take advantage of benefits.

The results are catastrophic for an industry which is frequently accused of charging members exorbitant fees. In truth, players are under siege from the steeply rising costs of healthcare, and while they are doing their best to limit the impact on members, this is no easy task when those very members are, in effect, stealing from the scheme through fraudulent claims.

The impacts are far-reaching for all stakeholders. Medical funds have no choice but to raise the price of contributions – after all, they need to maintain a steady pool of funds in order to be able to pay out claims, and if members are dipping into that pool for illicit reasons, it needs to be replenished. Naturally, this affects members severely, especially as many are already challenged by the rising cost of living. On the other side of the equation, practitioners also take a hit: when the pool of medical funds decreases, a less profitable practice is inevitable.

The prevalence of fraud is understandable when you consider that few controls are in place to prevent it. Think of the average consumer entering a retail chain pharmacy, for example: they may be asked to present their loyalty card, and while this may be considered a form of identification, the reality is that it is rather ineffective as a verification tool. The absence of an identification photo means that the purchaser could well be someone besides the patient for whom the script was written; nor is there anything to stop them from adding over-the-counter items to purchase and claiming them from their savings.

The good news? Fraud mitigation is both effective, and simple to implement. Establishing a ‘safety net’ of identity and biometric recognition makes it possible for medical schemes to ensure that members claim only for medicines and treatments they have been prescribed, while also protecting against scripts that have been falsified.

The result? A healthier medical aid industry – for the benefit of all.

Junior Biola is CEO of Johannesburg-based fintech company, Bitventure, a provider of state-of-the-art real-time automated verification and payment solutions. www.bitventure.co.za

Categories : Cardiovascular DiseaseTags :

Falling Victim to Fraud Has a Lasting Impact on Men’s Blood Pressure

On By ModernMedia

A new study published in the Journal of the American Geriatrics Society suggests that experiencing financial exploitation, fraudulent schemes, and scams may raise a person’s blood pressure, especially in later life. A key difference in the findings was that fraud victimisation was linked with elevated blood pressure in men, but not in women.

Instead of focusing on subjective measures of health after fraud vicitimisation, this study included objective measures of physical health, specifically, systolic and diastolic blood pressure, pulse pressure, and mean arterial pressure. Chronic elevation of these measures are known to contribute to end organ damage including stroke, cardiovascular disease morbidity, and mortality. 

The study participants consisted of 1200 older adults from the Rush Memory and Aging Project. During up to 11 years of annual observations, participants were asked about fraud victimisation and underwent serial blood pressure measurements.

In men, blood pressure elevations were observed after they had been the victims of fraud. Those elevations, compounded over time, could indicate future poor health. The rise in blood pressure persisted for years after the fraud had taken place, especially in old age.

“These findings show that fraud victimisation has important public health consequences and underscore the need for efforts to prevent exploitation,” said lead author Melissa Lamar, PhD, of Rush University Medical Center.

Source: Wiley

Categories : COVIDTags :

COVID Vaccines and Vaccination Certificates Sold on Darknet

On By ModernMedia

According to an article by BBC News, COVID vaccines and vaccination certificates are being widely sold on the darknet.

Prices can range from  $500 (R7500) and $750 for doses of the AstraZeneca, Sputnik, Sinopharm or Johnson & Johnson vaccines. Some even allow for emergency delivery with an overnight service. There are also fake vaccination certificates being sold for as little as $150.

Also known as the ‘dark web’, the darknet is a part of the internet that can only be accessed with specific browser tools. One such tool is Tor, a browser specially designed for anonymity.

Cyber-security company Checkpoint says that they have seen the number of adverts triple from when vaccines first become available, to 1200. The sources of the adverts appear to be the US, UK, Spain, Germany, France and Russia.

Oded Vanunu, head of product vulnerabilities research at Check Point told the BBC: “It’s imperative for people to understand that attempting to obtain a vaccine, a vaccination card or negative Covid-19 test result by unofficial means is extremely risky, as hackers are more interested in your money, information and identity for exploitation.”

Mr Vanunu also shared that,  as part of their research, his team purchased a Sinopharm vaccine dose from one of the vendors for $750, but are yet to receive it. His team believes that this particular vendor was a scammer, but others might be selling real vaccines.

Check Point is urging countries to protect their vaccine documentation by implementing a QR code system to make forgeries more difficult.

Source: BBC News