HEALTH INSURANCE FRAUD
GHANA’S PERSPECTIVE
NHIS@10 Conference
Dr. Lydia Dsane-Selby
Director, Claims
5th November 2013
Outline
Definition
Motivators
Types of Fraud & Abuse
Prevention/Mitigation
Pre-payment methods
Post –payment methods
The Way Forward
Definition
FRAUD:
• The crime of deceiving somebody in order
to get money or goods illegally.
• Intentional deception perpetrated for
profit or to gain some unfair or dishonest
advantage
Health Insurance Fraud
Health insurance fraud is 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.
Motivators - Providers
Wide range of potential medical conditions and
treatments to choose from
Fidelity to patients
Exploitation of loopholes in the provider payment
system
Inadequate fraud prevention and detection amongst
insurers
Often seen as a “victimless” crime
Limited sanctions and legal deterrents against public
sector facilities
Motivators - Members
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
Types of Fraud/Abuse - Providers
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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
Types of Fraud/Abuse - Members
 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
Ways to prevent/mitigate abuse
Policy methods – through appropriate payment
mechanisms
Each payment method has its advantages in
tackling certain types of abuse
Pre-payment methods – effective claims processing
Membership
Treatment protocols
Electronic vetting business rules
Post-payment methods
Data analysis
Clinical Audit & claims verification
Claims
Processing
Eligibility &
Membership
E-Vetting &
E-Adjudication
Provider
Payment
Paper
Claims
G-DRG
E-Claims
ICD-10
Treatment
Codes
Process, Business Rules Based Engine !!
Statistical
Data
22
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 treatment
Check that agreed tariffs for medicines and services have
been used
Claims Adjustments CPC v District
Post-Payment Methods
Data Analysis
Top 20 in-patient DRG’s for each specialty
Top 50 medicines diagnosed – by volume and by value
Service utilisation – OPD and IPD
Cost per claim for different provider types
Monthly value of claims per provider type per district
Month on month value of claims for each provider
Post-Payment Methods
Claims verification & Clinical Audit
Verify the attendance at the provider site
Verify the services given
Verify the medicines prescribed and dispensed
Contact members to confirm attendance,
services & medicines given
Assess the quality of care
Clinical Audit - Background & progress
• September 2009 – Claims & Clinical Audit Division
created
• January 2010 - Clinical audits commenced formally
• March 2010 – Separation of Clinical Audit Division
• June 2010 – Clinical Audit Manual developed
• December 2010 – Audit tools developed
• Biannual meeting with stakeholders to refine
process & discuss findings
• May 2013 – Clinical Audit & Accreditation merged
Clinical Audit Process
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Multi-disciplinary teams drawn from private & public sector.
Selection of auditee providers based on risk profile
Auditee providers selected from entire range of service provision
Prior notification of audit visits to ensure acceptance and results
Prior notification of clients whose folders have been selected for audit
Clients’ medical record/folders examined for:
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Linkage between treatment and diagnoses/adherence to treatment guidelines
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Accuracy of claims based on medicine dosage, strengths, and quantities
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Appropriateness of tariffs applied for services provided
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Evidence of co-payment
Exit conferences with management of provider facilities to discuss findings.
Furnishing of providers with draft report (including discussed findings, recommendations
and way forward
Opportunity for providers to dispute of findings and recommendations
Dispute resolution if required
Final report sent to providers (include claims deduction, dis-accreditation, recommendation
on quality improvement) with copies to umbrella organisations and associations
Follow-up on Recommendations through NHIA Regional Offices
Audited v Unaudited facilities
Category of findings
ERRORS
ABUSE
PROVIDERS
SCHEMES
FRAUD
CLINICAL
AUDIT
FINDINGS
QUALITY OF
CARE
Examples of fraud
• Public & Private facilities with same doctor
where 1524 patients visited exactly one month
apart
NAME
DATE (PUBLIC)
G-DRG
DATE (PRIVATE)
G-DRG
B. A.
18/10/2012
DENT18A
18/11/2012 (Sunday)
DENT18A
S. M.
24/4/2012
DENT19A
24/5/2012
DENT12A
G. B.
13/4/2012
DENT19A
13/5/2012 (Sunday)
DENT02A
N. A.
15/3/2012
DENTO2A
15/4/2012
DENTO2A
DENT02A = Surgical removal of tooth
DENT12A= Sialodectomy
DENT18A=Partial resection of the facial bones
DENT19A= Total resection of the facial bones & soft tissues
Examples of fraud
• Spurious claims – Facility puts in claims for
deliveries for patients who attended Antenatal
clinic but delivered elsewhere
• Recycling of claims from previous months to
boost numbers
• Recycling of patient details between facilities
The Way forward
Whistleblowers
Clean claims
Encourage whistleblowers and protect them by
legislation
Early reimbursement for providers with
clean claims. % tariff increase for
adherence to treatment protocols
% tariff increase
Training of health insurance staff in fraud
detection
Advocacy on
impact
Increased advocacy and sensitisation on
the impact of fraud and abuse on the
health insurance system
The Way forward
Legislation
Financial
penalties
Disaccreditation/
loss of license
Name and Shame
Pass specific health insurance fraud laws
making it a criminal offence e.g. USA
Health Insurance
Portability 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
CONCLUSION
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Health Insurance fraud is a global phenomenon
•
It cannot be eliminated entirely but can be minimised
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Methods to prevent fraud is insurance scheme and
country specific although there are general measures that
can apply to all
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There will always be loopholes in the medical scheme.
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Each time a loophole is closed, another is found.
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Insurers need to work with providers and members if the
prevention methods are to be successful.
Thank you
Merci
Gracias
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