Clinical rules in preventing/curbing p g gMedical aid fraud – 14 March ‘13

By Dr Jaco Makkink – POLMED Medical Advisor

Abstract conceptAbstract concept

Medical aid billing process?Medical aid billing process?

How do we get the pictureHow do we get the picture clearer?

1. Pt demographics– Membership noMembership no– Age– Gender– Address

2. Diagnosisg– ICD10 (International Statistical Classification of

Diseases and Related Health Problems (ICD), a medical classification list by the World Healthmedical classification list by the World Health Organization (WHO)

How do we get the pictureHow do we get the picture clearer? Continue:

3. Treatment– Non intervention (NHRPL coding)+TariffNon intervention (NHRPL coding) Tariff– Intervention/hospitalisation (CPT –

Current Procedural Terminology)+Tariff– Medication – Nappi codes+Tariff

Example:Example:

• 45 yr old ladyy y• From Nelspruit• ICD10 - I10 ESSENTIAL (PRIMARY) ( )

HYPERTENSION • NHRPL code – 0190 (New and established patient: (

Consultation/visit of new or established patient of an average duration and/or complexity. Includes

lli ith th ti t d/ f il dcounselling with the patient and/or family and co-ordination with other health care providers or liaison with third parties on behalf of the patient (forliaison with third parties on behalf of the patient (for hospital consultation/visit - refer to item 0173-0175 or item 0109) - not appropriate for pre-anaesthetic assessment followed by the appropriate anaesthetics - refer to new anaesthetic structure

Example continue:Example continue:

• Nappi code – 704929-001 Prexum Plus

Example of an accountExample of an account

What is fraud?What is fraud?

• In criminal law a fraud is an intentionalIn criminal law, a fraud is an intentional deception made for personal gain or to damage another individual;

• The specific legal definition varies by legal jurisdiction. Fraud is a crime, and also a civil law violation. Defrauding people or entities of money or valuables is a common purpose of fraudfraud.

• SOURCE: Wikipedia

Fraud in the medical aidFraud in the medical aid industry:

V “ ”• Very “gray”• Have to proof intentional deception

Cl li k ith li i N i d• Close link with negligence i.e. Nappi code• Unbundling of treatment codes?

Clinical rules in the adminClinical rules in the admin environment

• Close link between administration and managed healthcareg

1. Patient demographics: (Check/varify)– Member no/dependant nop– Age– Gender

2. ICD10 – next “filter”– This is the most important peace of information– The invoice is evaluated against the ICD10

code

Clinical rules in the adminClinical rules in the admin environment; continue:

NHRPL d

Nappid

codeCPT d

ICD 10

code code

ICD 10 code

Nappi code “rules”Nappi code rules

1. Age specific:g p– Dosage– Format (capsule, tablet, solution, PR, trans

dermally, inhalation, SL, IM, IV)– Refills– Quantity

2. Gender specific:OCT– OCT

– HRTTermination of pregnancy– Termination of pregnancy

Nappi code “rules”; continue:Nappi code rules ; continue:

3 ATC classification: (Anatomical Therapeutic3. ATC classification: (Anatomical Therapeutic Chemical classification) WHO

– Classified in 5 different levels– Level 1 – Anatomical area (Heart) C– Level 2 – Therapeutic main group (Diuretic) C03– Level 3 – Therapeutic sub group (High ceiling Diuretic)

C03CL l 4 Ch i l b (S lf id ) C03CA– Level 4 – Chemical subgroup (Sulfonamide) C03CA

– Level 5 – Chemical substance (Furosemide) C03CA01

NHRPL/CPT code rules:NHRPL/CPT code rules:

• Literally 100s of rules!y• Mainly gender specific• Examples:p

– 1. Hysterosalpingogram on a male – Decline– 2. Vasectomy on a female – decline– 3. Mammogram on a male – decline– 4. Sperm analysis on a female – decline– 5. Oophorectomy on a male – decline5. Oophorectomy on a male decline– 6. Salpingectomy/salpingostomy/salpingolysis on

a male – decline7 Dilatation and kurettation on a male decline– 7. Dilatation and kurettation on a male – decline

NHRPL/CPT code rules;NHRPL/CPT code rules; Continue:

• 8. Prostatectomy on a female – decline• 9. Prostate specific antigen analysis on a female – decline• 10. Hysterectomy on a male – decline• 11. Mastectomy on a male – FLAG• 12. Excision of gynecomastia in a female – decline• 13. Breast reduction in a male – decline• 14. Circumcision in female – decline• 15. Pregnancy test on a male – declineg y• 16. Orchidectomy in a female – decline• 17. Surgical correction of hypospadia in females – decline• 18. Surgical correction of priapisme in females – declineg p p• 19. Surgical procedures of the vulva on males – decline• 20. Surgical procedures on the labia in males – decline

NHRPL/CPT code rules;NHRPL/CPT code rules; Continue:

• 21. Surgical procedures on the spermatic cord in females – decline• 22. Vesico-vaginal fistula repair in a male – decline• 23. Anal-vaginal fistula repair in a male – decline• 24. Hysteroscopy on males – decline• 25. Endometrial biopsy in males – decline• 26. Insertion of IUD in males – decline• 27. Evacuation of uterus in males – decline• 28. 3 or more evacuations of the uterus in the same patient – FLAG• 29. Termination of pregnancy in a male – declinep g y• 30. Myomectomy in males – decline• 31. Procedures on the penis and claimed for a female – decline• 32. Biopsies on the testis, seminal vesicles and claimed by a female 3 ops es o e es s, se a es c es a d c a ed by a e a e

– decline• 33. Surgery to correct maldescended testis in a female – decline• 34. Operation for hydrocele or spermatocele in a female – declinep y p

Code “unbundling”:Code unbundling :

• Example:p– • Myringectomy = excision of the Tympanic membrane (ear

drum)• Myringoplasty = operative repair of a damaged tympanic– • Myringoplasty = operative repair of a damaged tympanic membrane

– • Myringotomy = paracentesis of the tympanic membrane (drainage of the middle ear usually by inserting “grommits” ( g y y g gthrough the tympanic membrane)

– • Tympanoplasty is a synonym of a Myringoplasty mentioned above.

– • Tympanotomy is a synonym of a Myringotomy mentioned above.

Number of consultationsNumber of consultations allowed per day:

• Massive problem!• Claims assessed retrospectively• “Flag” maximum allowed• ID provider• Drill down into claims• “Below radar” - low tariff, HIGH frequencyq y• Not only Drs, Auxillaries too

Short term insuranceShort term insurance

• Hollard/Clientele productsHollard/Clientele products• Waiting periods• Minor injuriesMinor injuries• Hospitalisation, battery of tests• Huge risk to funders• Huge risk to funders• Risk mitigating strategies

Recommendation:Recommendation:

• FMU used optimallyp y• Anti “collusion”• Same “culprits” over and overp• Exchange of information, especially in

relation to number of consults per day.y• Fine balance between “excessive control”

and “no control” i.e. number of consultations from GPs

Questions?Questions?