BHF360° | DECEMBER 2021
Emerging trends in healthcare
Healthcare fraud, waste and abuse – a case for collaboration The complexity and breath of healthcare FWA make it imperative for all affected stakeholders to work together, share information and data to correctly identify instances of FWA, and make efficient use of limited resources.
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iscussions on healthcare fraud, waste and abuse (FWA) have taken an unfortunate turn, which has pitted stakeholders in the healthcare industry against one another. This has made responses to this scourge very difficult and while all this is happening medical scheme beneficiaries are the ones that ultimately pay the price in the form of unsustainable contribution increases as well as benefit reductions. Health service providers (HSPs) have been placed at the centre of FWA, but while they may play a significant role, they are not the only ones responsible. Administrative staff at both medical schemes and HSPs are also involved, as are scheme beneficiaries. It’s also important to acknowledge that only a very small proportion of HSPs are involved in FWA, probably less than 5%. One needs to take a step back to fully understand why the healthcare industry is confronted with FWA. One
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must first acknowledge the complexity of the medical schemes industry. There are numerous benefit options that HSPs must grapple with; moreover the benefit option content is often presented in a complex way. The coding that is vital for submitting claims is not standardised across all schemes. This fragmented approach is further compounded by how schemes identify and investigate instances of FWA. Differing and inconsistent approaches make it more difficult for HSPs to respond to alleged instances of FWA. On the funder side, when instances of FWA are identified there is very little support in terms of prosecution and consequent management available to mitigate the losses suffered by schemes. Schemes have had to innovate to ensure that beneficiaries’ funds are protected. The responses by schemes have not been received well by HSPs. The sentiments of the provider community are captured in the section 59 investigation interim
B O A R D O F H E A LT H C A R E F U N D E R S
report. Indeed, the lack of regulatory oversight in FWA mitigation has made the situation worse. A consistent coding structure would help; a standardised tariff structure and a simpler and standardised benefit design would make the claiming process so much easier for providers. Even better would be alternative reimbursement models that incentivise good care for patients while placing less focus on billing and coding. Regulatory support in dealing with alleged FWA has also been lacking; hence funders have had to devise methods of limiting losses on their own. There is no firm understanding of the true cost of healthcare FWA. Perhaps if all stakeholders appreciated the true cost a multi-stakeholder response approach would be easier to implement. Industry-wide reports on losses should be instituted on an annual basis. This will help inform stakeholders of the urgent need for an appropriate response. Consequent
