Spike in claims trips up nurse with soaring income

When a registered nurse's income jumped from R10,000 to R500,000 a month an investigation led to a hospital - where he was unknown.

An analysis revealed a spike in claims related to an expensive intravenous feeding product, carried out at a hospital far from the nurse’s registered address.

The nurse admitted that a nursing sister employed at that hospital had shared patient information to facilitate fraudulent claims under the registered nurse's practice number.

The pair allegedly shared the proceeds and now face a criminal case of fraud in excess of R3m.

Sharing patient records for profit was just one of the types of fraud, waste and abuse  cases identified by Discovery Health in 2018.

Discovery said in a statement on Monday that its efforts to curb fraud and waste resulted in R555m being recovered on behalf of client schemes during 2018.

"We also estimate that the 'halo' effect of our extensive fraud, waste and abuse control activities has prevented additional fraud, waste and abuse to the value of about R5.1bn in the past couple of years,” said Discovery Health CEO Dr Jonathan Broomberg.

"This effect plays out as those who are contemplating fraud, waste and abuse desist from doing so, in reaction to visible action by Discovery Health and most likely other stakeholders as well."

Discovery has deployed more than 100 analysts and professional investigators, in addition to using forensic software to analyse claims data, to root out fraud.

Of the 5,443 cases that were reported last year for possible irregularities, concerns were confirmed in about 75% of investigations. Trends identified included:

• Limpopo topped the list of regions with the most fraud, waste and abuse cases investigated. The province was followed by the Free State and North West. The fewest fraud and waste cases originated from the Northern Cape.
• While the majority of health-care providers were honest, hard-working and ethical, "forensic investigations reveal that a minority of health-care professionals committed fraud against medical schemes, resulting in significant costs to schemes and their members", said Broomberg.
• Claims submitted for services not rendered (40%) topped the list of types of fraud and abuse cases, followed by capturing errors by a practice.

Examples of fraud, waste and abuse included the nurses who allegedly colluded to benefit from patient information. The registered nurse was subsequently dismissed.

"Although we have secured large recoveries as a result of our fraud, waste and abuse avoidance efforts, we believe that this is only part of the story, and fraudulent activity and billing abuse most likely costs medical aid schemes several billion rands a year. These precious funds could be used to pay for the critical health-care needs of our medical aid members," said Broomberg.