Fraud hurting health insurance

In 400 B.C, a Greek physician, Hippocrates, wrote what would later become one of the oldest and longest serving codes of contemporary medical practice, the Hippocratic Oath. Pivotal in the oath is a ritual of ushering new practitioners into the medical trade, illustrating what society and humanity at large expects of an individual in their position.

In 400 B.C, a Greek physician, Hippocrates, wrote what would later become one of the oldest and longest serving codes of contemporary medical practice, the Hippocratic Oath.

Pivotal in the oath is a ritual of ushering new practitioners into the medical trade, illustrating what society and humanity at large expects of an individual in their position.

Like when in the oath a graduate medical student states as indicated in the Declaration of Geneva that “The health of my patient will be my first consideration” it brings into context the “godly” nature in which Hippocrates’ Oath expected a physician to use their acquired knowledge and skills.

But it seems gone are the days when the focus of a medical practitioner was solely their patient’s health and wellbeing, especially at the hand of growing fraud in medical services (healthcare fraud).

Looking at global statistics, there has been an exponentially growing trend of healthcare fraud all to the detriment of medical insurance schemes effects which trickle down to burden the very patients (beneficiaries) that trained physicians are meant to protect.

An article by The Economist published on May 31 2014 claimed that medical fraud annually costs Medicaid and Medicare, America’s social security healthcare schemes, a whopping US$272 billion according to a study conducted in 2011, about Frw197trillion.

That amounted to more than 1.7% of the country’s total budget.

For Rwanda, the total loss in fraud has yet to be established yet, but one sure thing is; it is equally big in comparison to the country’s healthcare expenditure.

On one side of the malpractice, there are registered members subscribed to Rwanda Social Security Board (RSSB) - managed medical insurance who use their benefits to meet healthcare needs of ineligible persons.

These beneficiaries, though may do so with good intentions of supporting neighbours and relatives, end up causing loopholes in the scheme.

Under this, the subscribed RSSB member may visit a physician (well known to them) and have the latter prescribe medicine for another person who may or may not be present during the visit.

The prescriptions are then billed under the RSSB beneficiary’s account in the medical scheme.

Besides this, a more costly and troublesome form of fraud in Rwanda’s healthcare is that which is done by medical practitioners.

The malpractice by physicians, who are otherwise expected to work “godly” as Hippocrates put it, is fueled by the kickbacks given to doctors for any extra sum made for a health facility as investigations have revealed.

Informal agreements are said to exist between proprietors of particularly private health facilities and the medical staff requiring the latter to make increased revenue for the facility, and, in return, obtain a percentage of whatever they make.

These arrangements have also hurt healthcare in public hospitals where they do not exist.

For instance, many practitioners in public hospitals with part time jobs in private facilities give more time to the latter at the cost of patients in their former posts.

While the blame for increase in such fraud falls on medical professionals and beneficiaries, the role played by healthcare facilities in exacerbating the problem is not to be overlooked.

In this regard, healthcare facilities for instance require patients to pay cash for specific services and commodities, arguing that they are not catered for under the RSSB medical insurance scheme.

For instance, a patient having a C-section may be charged for gloves or drugs used separately and paid for with cash.

In other related cases, the unsuspecting patients pay 100% in cash for some medical operations, and fault RSSB for poor services.

However, for the RSSB viewpoint, together with its partner, we enter into contracts under which a list of medical services covered by the scheme is agreed upon and is renewable every six months.

This list, which is developed in collaboration with the Ministry of Health, medical services providers, and beneficiaries, is regularly reviewed to ensure that it meets current healthcare needs of members.

Thus, contrary to widespread allegations that there are some operations we partly cover fully.

Also, RSSB’s coverage includes many medical ailments and it is rare for a patient to find that their illness is not catered for by the medical insurance.

This implies that, in most cases, hospitals and pharmacies are serving selfish interests when they allege that certain drugs are not on the RSSB coverage list.

When they serve these interests, it’s our members that suffer-albeit unnecessarily.

What is being done?

To curb the malpractice, help desks have been set up at all big health facilities and are working 24 hours each day, especially in Kigali, where fraud is most prevalent.

Also, a medical bills’ verification process has been established with 45 officers stationed countrywide to crosscheck bills issued to RSSB by medical facilities, before payments are made.

In addition, an anti-fraud committee charged with investigating medical fraud cases to bring out details and slap penalties on culprits as provided for by law is operational at RSSB.

However, the paperwork is enormous and so is the room for error.

Considering the loopholes that exist in any of the measures taken so far, the only efficient means of curbing medical fraud in Rwanda is through solidarity of all beneficiaries; subscribed members and partner healthcare facilities.

Subscribed members of the medical scheme, medical professionals, health facilities, and all stakeholders need to take on the challenge head on.

The writer is the Director of Communications, Rwanda Social Security Board

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