Checks needed to prevent doctoring of claims

Checks needed to prevent doctoring of claims
The Pioneer Generation and Community Health Assist Scheme health benefit cards provide government subsidies to cardholders at private dental and general practitioners' clinics.

More than half a million people now have either the Pioneer Generation (PG) or the Community Health Assist Scheme (Chas) health benefit cards that provide government subsidies at private dental and general practitioners' clinics. As usage increases, more stringent  checks and balances need to be put in place to ensure that the money is correctly used.

Given the large number of doctors, clinics and patients involved, it is almost inevitable that a few would be tempted to claim more than their just dues.

This is not a slur on doctors in general, the vast majority of whom are ethical and morally upright. But any large group will throw up some rotten apples.

And the PG and Chas system is ripe for the picking.

Some people who would not dream of cheating individual patients may think it's perfectly acceptable to extract some extras from large, faceless payers - like the Government, insurance companies and corporations.

Last year, the United States Attorney-General's office recovered US$260 million (S$345 million) in medical fraud from 90 people, including doctors and nurses. Much of the money reclaimed came from claims made out for procedures that were never performed, or from kickbacks from pharmaceutical and equipment companies. In fact, since the US set up the multi-agency Medicare Fraud Strike Force in 2007, it has recovered US$6 billion in fraudulent claims.

Those who think that such criminal behaviour would not happen here need to think again - for it is already happening.

Remember the Singapore Medical Council cases against doctors for lax overprescription of sleeping pills? That's morally and legally wrong as it is making financial gains by feeding a potentially dangerous addiction.

Then, there is Making Health Connect (MHC), a third-party administrator with about 600 GPs on its panel. Among its clients are the majority of insurance companies here that provide primary care coverage, and several corporations. They pay all or the lion's share of the bills for clinic visits by patients under their coverage.

The group's ongoing audits resulted in about $500,000 being reclaimed last year from fraudulent claims from these clinics.

The litany of how some doctors and clinics in Singapore were gaming the system makes interesting reading. One doctor was giving patients generic drugs but making claims for a pricier branded one. Initially, the doctor disputed this, but caved in before the case went to court. He has since refunded more than $60,000 and also paid MHC's legal costs.

Another doctor was found out because he consistently gave patients only a week's worth of cholesterol tablets. People with high cholesterol levels need daily medication on a long-term basis, so a prescription of only a week's supply raised the red flag. A check found that the patients did not have high cholesterol levels and did not receive the pills.

A similar scam had a doctor prescribing a single Fosamax pill, for osteoporosis, which costs about $20. Fosamax, again, needs to be taken weekly over a long period. Again, the doctor was charging for a pill he did not give his patients.

One clinic charged for five scans for five kidneys in one patient. While this might truly be a clerical error, it would have meant higher charges to the payer than was necessary.

A clinic claimed for over 100 visits in a year by a single female patient. The signatures were different, and a check with the named patient revealed almost all of the claims to be false.

One doctor submitted claims for prescribing several bottles of lice shampoo to most of his patients. Why lice shampoo when lice is rarely encountered today? Likely because the brand was "A-Lices" shampoo - probably the first item on the computer's list of products.

There was also a doctor who claimed for five Arcoxia tablets purportedly given to every patient with cough or colds. Arcoxia is a branded anti-inflammatory painkiller. He skimmed about $63,000 over two years from this alone.

So, yes, defrauding the system does happen in Singapore too.

A police report was made in only one of the cases mentioned.

Dr Low Lee Yong, chief executive officer of MHC, said that the company is happy to recover the money and return it to clients. It also takes such doctors off its panel.

The Chas was launched in 2012 and the PG card last year. In just over a year, MHC, which has only about 600 GP clinics in its network, has recovered $500,000 in fraudulent claims.

This begs the question of whether there is similar abuse in the use of the Chas and PG schemes at other clinics. The two cards are accepted at about 1,300 GP and dental clinics. Yet, no reports have surfaced of wrong or fraudulent claims.

It isn't likely that dishonest doctors who cheat insurance companies and corporations suddenly become more scrupulous when it's the Government paying out the claims for patients who use the Chas and PG cards. It's more likely that some are cheating, but have not been caught.

It is incumbent on the Ministry of Health to put in stringent checks to ensure that taxpayers' money is not siphoned away by unscrupulous doctors.

One way of doing this is to have a data-collection system similar to what MHC uses, where claims must be accompanied by a breakdown of medication, procedures and consultation fees.

This way, computer algorithms can pick out unusual patterns when cheating occurs. Cheating is profitable only when done on a large scale, and not differing from patient to patient. This allows computers to pick out patterns.

A system that can sift out cheating has an added advantage of providing data on the state of health of the nation and can be used to track chronic disease management.

By deterring fraud and improving health management, such a system would surely pay for itself in more ways than one.

salma@sph.com.sg

facebook.com/ST.Salma


This article was first published on Jan 20, 2015.
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