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Tell the truth

General practitioners are seen to be honest, upright members of a community, yet probity issues are becoming more widespread. Dr Carmen Gerber looks at why probity and professionalism go hand in hand

Service provider fraud is on the increase, with the two most common causes being code manipulation and services not rendered.1Some healthcare practitioners are acting unprofessionally and unethically by loading patients’ bills with multiple codes instead of using one billing code for a procedure; claiming fees for services that were not rendered; or by performing unnecessary investigations.

Alarmingly, R221 million was attributed to medical aid fraud over the period 2007 – 2009 in a report by KPMG.1 These fraudulent activities have significant financial implications for South African citizens by further adding to the high cost of membership fees, making private healthcare unaffordable and inaccessible for many citizens. Fraudulent activities also harm the patient’s and the public’s trust and compromises a healthcare practitioner’s integrity, honesty and independence.

How are probity and professionalism linked?

Probity implies that a doctor will, at all times, act with integrity to protect patient and public trust in the medical profession.2 Medical professionalism allows doctors the independence to perform their duties with integrity3 and can be defined by qualities such as “humanism and altruism” (including ethical principles such as beneficence, respect, integrity, truthfulness and placing patients’ needs first) and “excellence and accountability”4 (including continuous education andproviding healthcare services of a high standard).

Medical professionalism can be viewed as a contract between the medical profession and society, with the doctor–patient relationship at the heart of this relationship

These ethical principles, as specified by the HPCSA, should form part of a doctor’s conduct with patients in practice. They should guide a healthcare practitioner’s decision-making process and actions.5 The HPCSA states that professionalism allows a relationship of mutual trust between patients and healthcare practitioners.6 Thus medical professionalism can be viewed as a contract between the medical profession and society, with the doctor–patient relationship at the heart of this relationship.

Society’s trust in doctors is dependent on the integrity of the individual doctor and the integrity of the medical profession as a whole.7 If a doctor’s behaviour does not conform to the HPCSA’s ethical and professional code of conduct, it is seen as unprofessional behaviour, compromising quality healthcare and risking patient safety.7 Doctors should act with integrity in all financial interactions with patients and medical schemes.8

The HPCSA states clearly that “healthcare practitioners shall not charge or receive fees for services not personally rendered, except for services rendered by another healthcare practitioner or person registered in terms of the Health Professions Act (Act No. 56 of 1974), which regulates the particular profession with whom the healthcare practitioner is associated as a partner, shareholder or locum tenens”.9

The HPCSA also cautions healthcare professionals on over-servicing patients, referring to unnecessary tests, scans, procedures or care.9

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

Doctors should ensure they act with probity and professionalism when submitting claims and never submit inappropriate, false or inflated claims

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

Top tips for accurate record keeping 

  • Sign and date all written and electronic notes.
  • Never change your notes, rather add a signed and dated amendment to it.
  • Corrections in notes must be shown as alterations and have to be signed and dated.
  • The relevant history and clinical findings, as well as decisions, discussions, information provided, investigations performed, results thereof, consent, referrals and patient progress should all be documented.
  • Never write any offensive comments in your notes.
  • Remember patients do have the right to access their own medical records (The Promotion of Access to Information Act 2000).

Case study

After sustaining a burn injury to his forearm on a Sunday afternoon, Mr C went to the local hospital, where he was received by Sister A. As Mr C was a private patient, Sister A conscientiously attended to obtaining his medical aid details and covered his arm with a burn shield, without obtaining a medical history from the patient or information on the events around the accident. Sister A then telephonically informed Dr Y, the doctor on duty for that day, of Mr C’s condition. Dr Y did not come to the hospital to see Mr C that day.

However, a few weeks later Mr C was surprised to find that a claim was made to his medical aid for an emergency consultation at the hospital for Dr Y (this was in addition to the costs claimed for the burn shield and hospital fee). Mr C felt this was unacceptable to be charged for a doctor’s consultation when the doctor did not consult with him at all. Mr C reported the matter to the HPCSA and an investigation was launched into his complaint.

Learning points:

  • Doctors should not charge patients for services they did not render.
  • Fraudulent activities should be reported to the HPCSA.

References

  1. KPMG Services (Proprietary) Limited 2011, Medical Schemes Anti Fraud Survey(accessed 18.5.13)
  2. MPS, Probity, Avoiding Easy Mistakes: Five Medicolegal Hazards for Junior Doctors (2011) (accessed 23.5.13) 
  3. Irvine D, The Performance of Doctors, I: Professionalism and Self-regulation in a Changing WorldBMJ, 314(7093):1540-1542, 1997 (accessed 20.5.13) 
  4. Buchanan AO, Stallworth J, Christy C, Garfunkel LC, Hanson JL,Professionalism in Practice: Strategies for Assessment, Remediation and Promotion, Pediatrics, 129(3): 407-409 (2012)(accessed 18.5.13)
  5. HPCSAGeneral Ethical Guidelines for the Health Care Professions, Booklet 1 (accessed 25.5.13)
  6. HPCSA, Ethical and Professional Rules of the Health Professions Council of South Africa, Government Gazette. Report number: 717 (2006) (accessed 25.5.13)
  7. Eisele DW, Professionalism: Why it Should Matter to Us (Presidential address at 2011 American Head and Neck Society Annual Meeting) Archives of Otolaryngology Head Neck Surgery 137(11):1071-1077, 2011 (accessed 20.5.13) 
  8. Hudson C, Practice Management: The Fight Against FraudMedical Chronicle(5.3.13) (accessed 18.5.13) 
  9. HPCSAGuidelines on Overservicing, Perverse Incentives and Related Matters, Booklet 5 (accessed 25.5.13)
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