Everything You Wanted to Know About Fraud and Practice in Health Service Industry and Were Afraid to Ask

 Fraud is one of the most retrogressive happenings in any sphere of life. Fraud affects all people directly or indirectly. The adverse effect of this in the healthcare industry cannot be over-emphasized. The main participants in fraud cases in healthcare include patients, healthcare service providers, suppliers of goods and services to the sector and brokers. In a nutshell “Fraud in Healthcare Kills”.

 

According to Jayesh Saini, healthcare fraud and corrupt practices ultimately affects the quality and quantity of services delivered, resources utilization, cost of services, time and human resources. In his opinion, this is one of the factors that have played a role in keeping cost of business to remain high and thus the high charges for service. Interestingly, from where he sits, as a consumer of services and an investor in healthcare, every one of the above participants in the sector blames all the others except themselves, making it sometimes difficult to solve the problem. This has led to each party, to the best of their ability, to make their personal efforts to ensure they are not defrauded by the other. Hundreds of millions are lost every year through fraudulent claims and this translates to stunted growth in the industry.

Generally, the main cause of involvement in fraud and corrupt practices is to increase profitability and reduce costs for the provider and to enjoy more benefits for less money for the consumer of the services, especially in an ever growing and competitive sector as the healthcare. This begs for clearer business practices and channels of verification of the transactions and processes.

 

Jayesh believes that unless the issue is dealt with once and for all especially at and from the national level, attainment of universal healthcare for all shall either remain a dream or it will be too expensive that it shall ultimately flop. Both of this should not be options but they sure will happen and the question is not if but when it shall happen. In his opinion, he believes that this can be eliminated or at least cut to insignificant amounts caused by human error rather than a deliberate action. This is possible if there is good will from all the parties and a willingness to invest in whatever technology is need.

 

Every service provider, whether a health facility or an insurance firm and supplier of goods and services should invest in a real time ICT that tracks all transactions. Any recipient of services and goods should be able to sign off for all services or goods received at any given time. The ideal signing off should be through a password protected account specific (with biometrics recognition) online signing where once signed and delivered to the service provider, the provider cannot edit the document. This document would then be uploaded to the payers claims portal with other supporting documents. This way, the supplier and the recipient of services would each have real time documentation on what has been supplied and what has been claimed. For the insured person they would always be aware of services rendered and the balance of their benefits. For the insurer, they would know what services their clients received and prices charged before paying for provider. To ensure there is no fraud through multiple claims by patients for the same condition within same time frame from different providers, interconnectivity of systems amongst service providers would ideally work.

 

With such a system in place, the never-ending story of healthcare fraud involving NHIF the largest insurer in Kenya would be a thing of the past. The private insurers would also have reduced if any claims they are rejecting and service providers would be unable to bill for services not rendered to the patients. The patients on the other hand would not be able to claim for services not delivered or through using someone else account (identity theft) or service provider hopping. Service providers would also not be able to double charge for a service especially in cases where an individual has both private insurance and the NHIF cover or separate procedures so as to claim more while the procedures are offered as a package where it applies. Patients would also receive value for money with no chances of being under served especially in so far as diagnostics and medications are concerned. This would translate to better health results for the person and for the country.