Understanding the types of fraud in claims to South African medical schemes

Legotlo, T G; Mutezo, Ashley Teedzwi

doi:10.7196/samj.2018.v108i4.12758

Cited by 7 publications

(5 citation statements)

References 6 publications

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“…This view is validated by a study that found that most of the fraudulent claims are perpetrated through the submission of false claims, irregular billing of codes, duplicate claims, claiming for services that were not rendered and card farming, which refers to members utilising medical aid benefits for a person not covered on the medical aid. 37 Nortjé and Hoffmann 38 also had similar findings and further noted that optometry recorded the third-most transgressions within the HPCSA, second to psychology and the medical professions, respectively. The negative impact of fraud on healthcare and healthcare financing is that it threatens sustainability and security of providing healthcare by driving up the cost of healthcare, impeding the provision of universal access to quality, affordable and timely healthcare.…”

Section: Discussionmentioning

confidence: 69%

Practitioner perceptions about optometric networks in South Africa

Maluleke

Moodley

2023

Afr. vis. eye health

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Background: Private healthcare in South Africa is largely financed by medical schemes. Optometrists reluctantly contract with administrators and networks to service these patients, despite them feeling networks are undesirable and exploitative. Networks contend that various mechanisms employed are necessary to ensure sustainability and prevent fraud, wastage and abuse. A working relationship between practitioners and networks should ideally be cordial and appreciated by each party as being mutually beneficial to the success of their respective businesses.Aim: To assess practitioners’ knowledge and perceptions regarding optometric networks.Setting: The study was conducted amongst optometric professionals in the private sector in South Africa.Methods: A descriptive, mixed-method study was conducted using a semi-structured questionnaire. Interviews with senior personnel from the networks were conducted.Results: Approximately 77% of respondents belonged to networks with 91% being knowledgeable about networks and their role within optometry. Opticlear had 72% members, while Iso Leso and preferred provider negotiators (PPN) had 67% and 41%, respectively. Most optometrists (69%) neither believed in the need for networks nor that they provide value to the profession, while 94.7% joined networks merely to receive direct payment and access patients, with no other benefits noted.Conclusion: Practitioners reluctantly contract to networks for direct payment and to access patients. Furthermore, practitioners feel that networks bully and victimise them while networks highlight their responsibility to reduce healthcare costs and negative practices of fraud, waste and abuse.Contribution: Providing sustainable, cost-effective and quality eye care services requires collaboration between networks and practitioners and appreciating each other’s roles in the delivery of eye care services.

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Section: Discussionmentioning

confidence: 69%

Practitioner perceptions about optometric networks in South Africa

Maluleke

Moodley

2023

Afr. vis. eye health

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“…Overall, moral hazard affects the normal operation of medical insurance funds. Identification of moral hazard behaviors and their occurrence mechanism is the first step in risk management ( 12 ). Therefore, the study aims to visualize the relationship of stakeholders and their moral hazard actions through social network analysis (SNA), and further explore the combination of conditions leading to funding loss by using crisp-set qualitative comparative analysis (cs/QCA) based on diamond fraud theory, to help Chinese governance to efficiently predict and investigate immoral behaviors in medical insurance and propose specific strategies to reduce moral hazards in the operation of medical insurance funds.…”

Section: Research Status Of Moral Hazards In China's Medical Insuranc...mentioning

confidence: 99%

“…The NHS Fraud Authority (NHS CFA) predicted that in the UK the NHS costs around £1.27 billion due to moral hazards such as fraud annually ( 11 ). According to the cases of sanctioning healthcare professionals in South Africa, 51.7% of ethical transgressions were for insurance fraud, and the amount lost per year is about ZAR 13 billion in private healthcare sectors ( 12 , 13 ). Statistics for some Asian countries are also appalling.…”

Section: Introductionmentioning

confidence: 99%

How do moral hazard behaviors lead to the waste of medical insurance funds? An empirical study from China

Qin

Liu

et al. 2022

Front. Public Health

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ObjectiveThe huge loss of health insurance funds has been a topic of concern around the world. This study aims to explore the network of moral hazard activities and the attribution mechanisms that lead to the loss of medical insurance funds.MethodsData were derived from 314 typical cases of medical insurance moral hazards reported on Chinese government official websites. Social network analysis (SNA) was utilized to visualize the network structure of the moral hazard activities, and crisp-set qualitative comparative analysis (cs/QCA) was conducted to identify conditional configurations leading to funding loss in cases.ResultsIn the moral hazard activity network of medical insurance funds, more than 50% of immoral behaviors mainly occur in medical service institutions. Designated private hospitals (degree centrality = 33, closeness centrality = 0.851) and primary medical institutions (degree centrality = 30, closeness centrality = 0.857) are the main offenders that lead to the core problem of medical insurance fraud (degree centrality = 50, eigenvector centrality = 1). Designated public hospitals (degree centrality = 27, closeness centrality = 0.865) are main contributor to another important problem that illegal medical charges (degree centrality = 26, closeness centrality = 0.593). Non-medical insurance items swap medical insurance items (degree centrality = 28), forged medical records (degree centrality = 25), false hospitalization (degree centrality = 24), and overtreatment (degree centrality = 23) are important immoral nodes. According to the results of cs/QCA, low-economic pressure, low informatization, insufficient policy intervention, and organization such as public medical institutions, were the high-risk conditional configuration of opportunism; and high-economic pressure, insufficient policy intervention, and organizations, such as public medical institutions and high violation rates, were the high-risk conditional configuration of risky adventurism (solution coverage = 31.03%, solution consistency = 90%).ConclusionThere are various types of moral hazard activities in medical insurance, which constitute a complex network of behaviors. Most moral hazard activities happen in medical institutions. Opportunism lack of regulatory technology and risky adventurism with economic pressure are two types causing high loss of funds, and the cases of high loss mainly occur before the government implemented intervention. The government should strengthen the regulatory intervention and improve the level of informatization for monitoring the moral hazard of medical insurance funds, especially in areas with low economic development and high incident rates, and focus on monitoring the behaviors of major medical services providers.

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“…In particular, in some high-income countries, 3–10% of annual healthcare expenditures are lost as a result of health insurance fraud, amounting to billions of dollars [ 6 – 9 ]. However, due to the unique characteristics of the health insurance industry and the complex and insidious of health insurance fraud, the supervision of health insurance funds is very difficult [ 10 , 11 ].…”

Section: Introductionmentioning

confidence: 99%

What influences the public’s willingness to report health insurance fraud in familiar or unfamiliar healthcare settings? a cross-sectional study of the young and middle-aged people in China

Xu,

Zhang,

Zhang

et al. 2024

BMC Public Health

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Introduction Young and middle-aged people are important participants in the fight against health insurance fraud. The study aims to investigate the differences in their willingness to report health insurance fraud and the factors influencing it when it occurs in familiar or unfamiliar healthcare settings. Methods Data were obtained from a validated questionnaire from 828 young and middle-aged people. McNemar’s test was used to compare the public’s willingness to report under the two scenarios. Chi-square tests and multiple logistic regression analysis were used to analyze the determinants of individuals’ willingness to report health insurance fraud in different scenarios. Results Young and middle-aged people were more likely to report health insurance fraud in a familiar healthcare setting than in an unfamiliar one (McNemar’s χ²=26.51, P < 0.05). Their sense of responsibility for maintaining the security of the health insurance fund, the government’s openness about fraud cases, and the perception of their ability to report had significant positive effects on the public’s willingness to report in both settings (P < 0.05). In a familiar healthcare setting, the more satisfied the public is with government measures to protect whistleblowers, the more likely they are to report (OR = 1.44, P = 0.025). Those who perceive the consequences of health insurance fraud to be serious are more likely to report than those who perceive the consequences to be less serious (OR = 1.61, P = 0.042). Conclusion Individuals are more likely to report health insurance fraud in familiar healthcare settings than in unfamiliar ones, in which their awareness of the severity of the consequences of health insurance fraud and their perceived risk after reporting it play an important role. The government’s publicizing of fraud cases and enhancing the public’s sense of responsibility and ability to maintain the safety of the health insurance fund may be a way to increase their willingness to report, regardless of whether they are familiar with the healthcare setting or not.

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Understanding the types of fraud in claims to South African medical schemes

Cited by 7 publications

References 6 publications

Practitioner perceptions about optometric networks in South Africa

Practitioner perceptions about optometric networks in South Africa

How do moral hazard behaviors lead to the waste of medical insurance funds? An empirical study from China

What influences the public’s willingness to report health insurance fraud in familiar or unfamiliar healthcare settings? a cross-sectional study of the young and middle-aged people in China

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