Council for Medical Schemes hosts fraud, waste and abuse summit

From 28 February to 1 March, the Council for Medical Schemes will host its inaugural Fraud, Waste and Abuse summit at the Sandton Convention Centre in Johannesburg.

The summit will bring together medical schemes, administrators, managed care organisations, policymakers and other stakeholders to discuss strategies for dealing with fraud, waste and abuse in the industry.

The intended outcome of the summit is to get stakeholders to sign an industry charter as a pledge to combat fraud, waste and abuse in the private healthcare sector. Future outcomes include the establishment of standards for the industry to effectively deal with fraudulent activities, including fair sanctions for convicted fraudsters, as well as the establishment of a structure to continuously deal with these issues.

“All healthcare stakeholders, including medical scheme members, healthcare providers and professionals, as well as the law enforcement authorities, have a significant role to play in combating this growing challenge,” said Sipho Kabane, chief executive officer and registrar of the council.

According to the council, fraud refers to an intentional deception, false statements or false representation of material facts with the knowledge that the deception could result in unauthorised benefit or payment for which no entitlement would otherwise exist. Abuse is described as practices that are inconsistent with sound fiscal, business or medical practices and which result in an unnecessary cost to a medical scheme, or in reimbursement for services that are not medically necessary. Waste refers to the extra costs incurred when healthcare services are overused, or when bills for services are presented incorrectly, and usually caused by a mistake rather than illegal or intentional wrongful actions.

According to Kabane, fraud, waste and abuse presents itself in various forms, and is carried out by different stakeholders within the industry, including some healthcare professionals (doctors, pharmacists, etc.), members and medical schemes. “Fraud, waste and abuse also presents itself by way of over-billing for services or supplies, falsifying patient data to obtain payments from medical schemes, referring patients to specific specialists or hospitals in return for kickbacks, as well as misrepresenting diagnoses and miscoding of claims to obtain payments or more money than justified,” he said.

“All these are costing the industry more than R22 billion per year.”

The negative effects of these issues in the private healthcare sector are far-reaching and continue to seriously undermine the stability of the health industry, infringing on the values of democracy, justice and the rule of law. It is the ordinary members of medical schemes that bear the burden of high medical scheme contributions. “The current state of affairs is unsustainable. Collectively, all stakeholders need to come together in developing a workable solution to addressing the challenge.”

Speakers during the summit will include the Council of Medical Schemes’ chief executive officer and registrar, Dr Sipho Kabane, head of the Special Investigating Unit, Advocate Andy Mothibi, as well as key role players from the industry.

Also check out:

https://www.citizen.co.za/sandton-chronicle/213808/notice-road-closures-around-sandton-convention-centre-africa-investment-forum/