If you have ever been to a doctor or dentist or hospital, you may have experienced a sense of nervousness, discomfort, uncertainty … some call it F.E.A.R. – False Evidence Appearing Real!
However you state it – other medical terms call it ‘White Coat Syndrome’ – when you see a white coat, you can go into a state of shock and disorder almost instantly. I guess it all makes sense now when I see my wife wearing a white coat around the house, more regularly than before!
When we think about Healthcare, we tend to focus on costs that relate to medical bills, hospitalisation, medical aid plans, and so on. What we need to understand from a risk management perspective is that Healthcare is a diverse entity that will take more than a single-prong or two-prong approach to manage effectively. Each person, group or organisation has different medical requirements; so the solutions are also diverse, while still trying to provide a ‘one size fits’ to most medical/health plans.
So let’s look at one side of the healthcare coin – fraud!
In the USA, the National Healthcare Anti-Fraud Association (NHCAA) gives an unofficial estimate that anywhere between $70 billion and $234 billion is lost annually. This figure represents between 3 – 10 % of the $2,34 trillion Americans spent on healthcare in 2008.
In South Africa, mention is made about R8 billion a year being lost owing to fraud.
(Source: http://www.iol.co.za/news/south-africa/medical-aid-fraud-to-top-r8bn-a-year-1.429833 )
In the recent Association of Certified Fraud Examiner 2010 Report to the Nation Fraud Survey, the Healthcare Industry was the fifth highest targeted area of fraudsters in terms of frequency, followed by Retail (fourth), Government and Public Administration (third), Manufacturing (second) and Banking / Financial Services (first).
So, the Healthcare Industry remains a target area for those opportunists out there, whether they be a Dr Who, Dr Zhivago, Dr Dolittle, Dr Frankenstein, Dr Jekyll (and Mr Hyde) or a Dr No.
It doesn’t matter whether you are an English Patient, knew Nurse Betty or even had dealings with Patch Adams, the quest to become more patient-centred is that often the patients (in collusion with doctors) are taking their patient-centredness to new levels.
As there are discussions in South Africa about the National Health Insurance System, we should start to take stock of the prevalence of fraud and abuse and start to implement and introduce proactive measures within both our current health insurance systems and those that are to follow.
We talk about diagnosis, care and cure in healthcare circles. The same applies for risk management in this space:
1. How well have we diagnosed the issues of fraud and abuse in our healthcare plan, be it individual, family or group-based?
2. What are we doing to ensure proper care is provided in both the treatment we receive and pay for – does it all add up? Do you check your statements or just submit and ignore what you receive in the post/email?
3. Where are we looking for those proactive cures to ensure that we remain FraudFit and healthy?
4. The list goes on … is there more that we should be doing?
Let’s get F4F – Fit for Fraud.
