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Dr. Lydia Dsane-SelbyDirector, Claims

National Health Insurance Authority, Ghana

Effective methods of preventing and mitigating medical scheme abuse

15th August, 2013

2013 GEMS Annual SymposiumProtecting GEMS value against benefit abuse

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Outline of Presentation

Motivators

Definition

Prevention/Mitigation methods

Types of fraud and abuse

The way forward

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DefinitionABUSE: The use of something in a way that is wrong or harmful. (Oxford Advanced Learner’sDictionary)

FRAUD:The crime of deceiving somebody in order to getmoney or goods illegally.(Oxford Advanced Learner’s Dictionary)

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HEALTH INSURANCE FRAUD Health insurance fraud is described as an intentional act of

deceiving, concealing, or misrepresenting information that results in health care benefits being paid to an individual or group.

Fraud can be committed by both a member and a provider.

Definition

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Wide range of potential medical conditions and treatments to choose from

Ability to spread false billings among many insurers

Fidelity to patients Exploitation of loopholes in the provider

payment system Inadequate fraud prevention and detection

amongst insurers

Motivators - Providers

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Misconceptions about insurance – victimless crime, insurers have lots of money

Mutually beneficial to parties involved Exploitation of loopholes Financial gain Limited legal deterrents or sanctions

Motivators - Members

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Areas of fraud

Source: Google Images

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Billing for services not rendered Up-coding of services Double billing/Duplicate claims Misrepresentation of diagnosis Unbundling of services Unnecessary services Inappropriate referral for financial gain Insertion/Substitution of medicines Unauthorised co-payments Limited sanctions and legal deterrents against

public sector facilities

Types of fraud/abuse - Providers

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Impersonation – a non-member using a member’s identity

Ganging – all the family using one member’s card Provider shopping Illegal cash exchange for prescriptions Frivolous use of services – drugs for sale

Types of fraud/abuse - Members

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Tampering with eligibility dates – fast tracking to avoid waiting period

Incomplete vetting of claims – claims that should be adjudicated downwards are allowed to pass

Collusion with providers – staff colluding with a provider to inflate claims and take a kickback

Types of fraud/abuse - Insurer

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Ways to prevent/mitigate abuse

Policy methods – Payment mechanisms - Each payment method has its advantages in tackling certain types of

abuse Good ICT – electronic claims submission and vetting Robust membership authentication - registration and point of service Sensitisation of members – on impact of fraud and abuse

Pre-payment methods – effective claims processing Membership Treatment protocols Electronic vetting business rules Statement of benefit – members can verify the claims submitted on their behalf

Post-payment methods Data analysis Clinical Audit & claims verification Good investigation and prosecution capacity

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Policy Methods

Provider Payment Mechanisms Capitation –control unnecessary services, duplicate claims, membership

fraud and abuse.may lead to underservicing, unauthorised co-payments

DRG – control over billing, over servicing, unnecessary services, non-adherence to treatment protocols

may lead to unbundling, up-coding of the tariffs Fee for service – control underservicing,

may lead to oversupply, insertions of medicines, substitution of medicines

Benefit Package Explicit inclusion list Specific exclusion list Reimbursable medicines list

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Policy Methods

ICT Nationwide database of members and providers Membership authentication at provider sites - biometric Electronic claims submission with a claims check code

Sensitisation of general public Types of fraud National impact of fraud Financial implications for the sustainability of the scheme Health implications of fraud and abuse for members

growing stronger & healthierProcess, Business Rules Based Engine !!

E-Vetting & E-Adjudication

Eligibility & Membership

Treatment Codes

ICD-10

G-DRG

PaperClaims

E-Claims

Provider Payment

StatisticalData

22

Claims Processing

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Pre-Payment Methods Claims management – Electronic & Manual

Biometric authentication at provider site – eligibility & membership – generate claims check code

Member unique ID number checked against membership database when claims submitted

Alert for any claims using the same unique ID number within the last month at any provider

Check appropriateness of diagnosis against age and gender

Check match between diagnosis and treatmentCheck that agreed tariffs for medicines and services have

been used

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04/20/2023

Ashanti

Brong A

hafo

Central

Eastern

Greate

r Acc

ra

Northern

Upper East

Upper West

Volta

Weste

rn CPC0%

2%

4%

6%

8%

10%

12%

2.00%

3.50%

2.00%1.00%

3.00% 3.00%4.00% 4.00%

3.00%2.00%

11.00%

Comparing Claims Adjustments at CPC to Nationwide (2011)

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Post-Payment Methods Data Analysis

Top 20 in-patient DRG’s for each specialtyTop 50 medicines diagnosed – by volume and by valueService utilisation – OPD and IPD Cost per claim for different provider typesMonthly value of claims per provider type per districtMonth on month value of claims for each provider

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Post-Payment Methods

Claims verification & Clinical AuditVerify the attendance at the provider siteVerify the services givenVerify the medicines prescribed and dispensedContact members to confirm attendance,

services & medicines givenAssess the quality of care

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Post-Payment Methods

Develop Investigation & Prosecution capacityGood and accurate documentationEvidence gatheringKnowledge of the appropriate lawsEducation of police and prosecutors on medical

fraudSpecial medical fraud prosecution unit

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KEY FINDINGSCost retrieval

ASHANTI

BRONG-AHAFO

CENTR

AL

EAST

ERN

GREATE

R ACCRA

NORTHER

N

UPPER EA

ST

UPPER W

EST

VOLTA

WES

TERN

-

5,000,000.00

10,000,000.00

15,000,000.00

20,000,000.00

25,000,000.00

30,000,000.00

35,000,000.00

40,000,000.00

45,000,000.00

Cost retrieval

COST RECOVERY (DEDUCTION)CLAIMS PAID

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Incentives

WhistleblowersEncourage whistleblowers and protect them by legislation

Early reimbursement for providers with clean claims. % tariff increase for adherence to treatment protocols

Training of health insurance staff in fradu detection

Increased advocacy and sensitisation on the impact of fraud and abuse on the health insurance system

Clean claims

% tariff increase

Advocacy on impact

The Way forward

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Deterrents

LegislationPass specific health insurance fraud laws making it

a criminal offence e.g. USA Health InsurancePortability and Accountability of 1996 (HIPAA)

Financial penalties above repayment of fraudulent payments

Health care provider should lose its license with the regulatory bodies as well as disaccreditation by the insurer

Public gazetting of fraud and abuse cases

Financial penalties

Disaccreditation/ loss of license

Name and Shame

The Way forward

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CONCLUSION

Health Insurance fraud is a global phenomenon It cannot be eliminated entirely but can be minimised Methods to prevent fraud is insurance scheme and country specific

although there are general measures that can apply to all There will always be loopholes in the medical scheme. Each time a loophole is closed, another is found. Insurers need to work with providers and members if the prevention

methods are to be successful.

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Thank YouDankie

Ngiyabonga