HEALTH INSURANCE FRAUDGHANA’S PERSPECTIVE

NHIS@10 Conference

Dr. Lydia Dsane-SelbyDirector, Claims

5th November 2013

Outline

DefinitionFRAUD:

•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 - ProvidersWide range of potential medical conditions and treatments to choose fromFidelity to patientsExploitation of loopholes in the provider payment systemInadequate fraud prevention and detection amongst insurersOften seen as a “victimless” crimeLimited sanctions and legal deterrents against public sector facilities

Motivators - MembersMisconceptions about insurance – victimless crime, insurers have lots of moneyMutually beneficial to parties involvedExploitation of loopholesFinancial gainLimited legal deterrents or sanctions

Types of Fraud/Abuse - Providers 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 abusePolicy methods – through appropriate payment mechanisms

Each payment method has its advantages in tackling certain types of abuse

Pre-payment methods – effective claims processingMembershipTreatment protocolsElectronic vetting business rules

Post-payment methodsData analysisClinical Audit & claims verification

Process, 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

Pre-Payment Methods Claims management – Electronic & Manual

Biometric authentication at provider site – eligibility & membership – generate claims check codeMember unique ID number checked against membership database when claims submittedAlert for any claims using the same unique ID number within the last month at any providerCheck appropriateness of diagnosis against age and genderCheck match between diagnosis and treatmentCheck 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 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

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

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• 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:

Linkage between treatment and diagnoses/adherence to treatment guidelines Accuracy of claims based on medicine dosage, strengths, and quantities Appropriateness of tariffs applied for services provided 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

Examples of fraud• Public & Private facilities with same doctor

where 1524 patients visited exactly one month apart

DENT02A = Surgical removal of toothDENT12A= SialodectomyDENT18A=Partial resection of the facial bonesDENT19A= Total resection of the facial bones & soft tissues

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

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

WhistleblowersEncourage whistleblowers and protect them by legislation

Training of health insurance staff in fraud 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

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

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

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.

Thank youMerciGracias

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