Medical aid probes
Medical schemes are identifying more doctors suspected of fraudulent activities through probes.8 Doctors are being probed by medical schemes that send investigators (wired) as undercover patients for consultations to practices. Attention is paid to what the doctor prescribes, dispenses, bills and claims for the consultation. In certain situations, doctors will dispense cheaper drugs and claim for more expensive drugs from the medical scheme or add additional procedural codes (not performed during the consultation) to the bill.8
Doctors should ensure they act with probity and professionalism when submitting claims and never submit inappropriate, false or inflated claims. If such claims are made intentionally it is regarded as fraud, in which case MPS would be unlikely to provide assistance; and the relevant healthcare practitioner will also probably be investigated by the HPCSA.8
Medical aid fraud is classified as “personal misconduct that does not directly relate to the practice of medicine”.8 The HPCSA protects the public and guides healthcare professionals. Nowadays, patients are more informed of their rights and responsibilities and the HPCSA encourages them to report doctors that are unprofessional in their conduct.
Furthermore, it is the responsibility of healthcare practitioners to report any activities relating to fraud or misconduct. The HPCSA stipulates that “a student, intern or practitioner shall report any unprofessional, illegal or unethical conduct on part of another student, intern or practitioner”.6 MPS encourages healthcare professionals to keep accurate medical records. These records reflect what has taken place in the consultation and the quality of care given to patients.
Good records can also form the basis of a doctor’s defence in future litigations. To protect doctors’ independence and the medical profession’s credibility, doctors should act with professionalism and probity. To prevent fraud, unprofessional behaviour should not be tolerated, doctors should be trained and educated on professionalism during their undergraduate training, they should reflect on their own behaviour and modify it appropriately in their daily practice and continue to learn about professionalism throughout their career.7