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Probing for answers

Report Healthcare Fraud’; ‘Call the Fraud Hotline’; ‘Would You Recognise Healthcare Fraud?’ and ‘Fraud is Wrong’.

Visitors to the website of the anti-fraud division of Health and Social Care (HSC) Northern Ireland are confronted by these headline messages. The home page displays a hotline number, an online reporting mechanism, explanatory educational videos and links to its Twitter and Facebook pages, albeit its social media following is small.

It is an exercise in active engagement: naming the problem, encouraging and facilitating reporting, and investigating. In 2015/2016, the main types of fraud investigations undertaken by Counter Fraud and Probity Services (CFPS) in Northern Ireland related to prescription fraud, patient entitlement, financial abuse (mainly social care), travel and subsistence, and student bursaries, a spokesperson informed the Medical Independent (MI).

During 2015/2016, according to the CFPS Performance Report published on its website, it worked on a total of 214 fraud investigations. It recovered £112,000 as part of its post-payment verification exercises and, separately, 21 convictions were secured for a range of fraud offences, among other actions (see panel, p5).

South of the border, the CFPS’s closest replicate is arguably the HSE Internal Audit Division, although the comparison is very loose in many respects. Notably, Internal Audit is generally not as well promoted as a mechanism through which concerns should be directly disclosed.

The Internal Audit Division, which had approximately 40 staff in 2015, has a direct link to the Executive’s top echelon, as National Director Mr Michael Flynn is on the HSE Leadership Team.

Internal Audit’s jurisdiction encompasses all systems and activities in the HSE and HSE-funded bodies. It conducts nationwide audits, as well as special projects and investigations in collaboration with specialist forensic accounting contractors, if required.

Detailed questions were submitted to the HSE on the work of Internal Audit, and its current manpower and resourcing, but no response had been received by press time.

Uncomfortable truth

Manipulating resources in healthcare represents a low in human behaviour that many find difficult to countenance, yet the lesson from history is to expect the unexpected.

This uncomfortable truth has been evident in recent weeks in the context of ongoing revelations about the suicide prevention and support charity Console, first exposed by RTÉ Investigates in June.

In the wake of the controversy, it has been suggested that alarm bells concerning Console were sounded within the HSE and Department of Health several years ago.

The HSE internal audit of Console began in May 2015 and auditors very quickly realised that things were amiss. The work of HSE Internal Audit appears to have been extensive but was hampered by obfuscation on the part of former Console CEO Mr Paul Kelly. It remains unclear how or why Mr Kelly remained in situ until June 2016.

The need for a more unified approach has been underlined by the Console debacle, but how the reporting of concerns and audit and accountability might be better linked remains uncertain, as does the shape of things to come in the context of health sector restructuring.

A number of Hospital Groups, for example, have confirmed to MI that they have no current plans to develop their own internal audit functions.

As a spokesperson for the Saolta University Health Care Group remarked: “The Group’s internal audit function is provided by the HSE’s Internal Audit function. The structure of internal audit into the future will depend on decisions made when Groups are established on a legislative basis.”

The HSE has a conglomerate of policies, reporting pathways and a Confidential Recipient for Vulnerable Persons. It has policies on ‘good faith’ reporting, protected disclosures and on fraud and corruption.

There were seven disclosures in 2014 and nine in 2015 to the HSE Authorised Person (installed under the Health Act 2007). Thirteen concerned the health/welfare of patients, one concerned staff health/welfare, one concerned alleged financial mismanagement and the remaining one concerned alleged financial mismanagement and a patient health/welfare issue. Four disclosures were made under the Health Act 2007 and 12 under the Protected Disclosures Act 2014.

There were no ‘good faith’ reports received during 2014 or 2015. Controversially, the HSE has delayed updating its guidance on whistle-blowing to include reference to the Protected Disclosures Act 2014. The legislation, which commenced two years ago, is described by Transparency International as reflecting international best practice.

Meanwhile, the Confidential Recipient received 119 concerns during 2015. Some 43 related to alleged abuse (physical, sexual, psychological, financial, neglect, discrimination and institutional). Three further concerns related to “financial charges”.

Mr Stephen McMahon, head of the Irish Patients Association, believes that the posited centralised purchasing authority in a reconstituted health sector will require an “internal, independent audit process”.

It should have direct reporting authority to the HSE Director-General or the Minister for Finance, as examples. The role of the Comptroller and Auditor General could also be expanded.

Mr McMahon said reporting potential fraud and irregularities should be made much easier, such as through hotlines and similar open-access reporting mechanisms.

He added that he supported “right-touch regulation” that was effective but not excessively bureaucratic. Mr McMahon would also advocate compulsory training on governance for people sitting on NGO boards in the health and social care spheres.

Maximising eHealth technologies as monitoring tools, eg, prescribing patterns among doctors, would also help to ensure better control over service delivery, he said.

Mismanagement of resources and under-performance also have a hugely negative impact on society and must not be overlooked, he emphasised.

Healthcare professionals

Some point to a general reluctance to challenge or report authority figures due to fears of the ‘downstream effect’ as helping to sustain irregular and fraudulent practices.

Cork-based dentist Dr Liam Lynch is author of Occupational Fraud in Publicly Funded Dentistry — The Elephant in the Room, which was published in 2015. Dr Lynch told MI it has been well received by healthcare professionals.

“Most healthcare professionals believe that an efficient probity assurance system should be in operation in a payment agency,” Dr Lynch informed MI. “Fairness to the healthcare professional, the user and the funder is the key thing and my book emphasises this.”

Some would contend that there is still a paternalism around delivery of specialist medical and dental care and that colleagues, patients and authorities can feel uncomfortable in confronting so-called ‘white-collar’ fraud.

“White-collar crimes are notoriously difficult to prosecute,” stated Dr Lynch. “Fraud in healthcare is a good example, often due to the asymmetry of information between the professional and the client. I don’t think paternalism enters into it as frequently as is suspected.”

Dr Lynch noted ongoing activities to increase awareness of healthcare fraud. “I am aware of a probity roadshow put on by the Irish Dental Association. I teach a postgrad course in healthcare fraud to the Masters in Healthcare Law and Ethics in the RCSI Dublin. And I have lectured in University College Cork in CPD to dentists on the topic. So there is a fair current interest in the subject, at least in dentistry, at the moment.”

Is there a belief among many healthcare professionals that the HSE’s audit and probity apparatus needs to be enhanced? Dr Lynch suggested that systems definitely need to be “reappraised”.

Medical organisations have tended to say relatively little on tackling fraud and irregularities within the profession, publicly at least. However, as in every walk of life and all facets of healthcare, some doctors have also engaged in fraudulent and irregular practices.

This was clear from the Review of Measures to Reduce Costs in the Private Health Insurance Market 2013 (the McLoughlin report), an independent report published by the Department of Health.

This report noted that while the majority of healthcare providers are “honest and well intentioned”, there was evidence of “abuse in the system”. This included, among other aspects, consultant upcoding of procedures, consultants claiming benefit when they were not present or had not personally performed the procedures, and cross-specialty referrals when they were not strictly clinically necessary.

Speaking to MI, one healthcare source felt that deliberate upcoding of procedures was “difficult to police” and, in their view, complicated by the coding systems.

This newspaper contacted the IHCA by phone and email, requesting comment and for details on its work on promoting probity. However, there was no response by press time. The IMO did not respond specifically to questions on these issues but noted as relevant its papers on Preserving Medical Professionalism in an Increasingly Commercial Healthcare Environment; and its submission to the Department of Health, Consultation on the Draft Money Follows the Patient — Policy Paper on Hospital Financing.

The later cites the need for “accurate data, including correct classification, exact pricing of conditions and proper length of stay guidelines” in order to address “unintended consequences and perverse incentives”. The former expressed concern over incentives to over-treat in private healthcare. It also noted: “Many doctors are critical of reimbursement procedures by health insurance companies and their willingness to reimburse more expensive MRIs over less expensive diagnostic procedures such as a CT scan or x-ray, whether the tests are clinically indicated or not.” 

The McLoughlin report recommended that the health insurance industry fund a “whistle-blower initiative” with an online anonymous reporting facility, hotline facilities and actively promote the initiative within the customers of the industry and public and private providers.  

An Insurance Ireland spokesperson informed MI that it has a dedicated phone line and website, www.insuranceconfidential.ie. However, data on contacts with this service was not made available to MI. Insurance Ireland holds a Health Claims Forum to support “the application of best practice” in the identification and tackling of “waste and inefficiencies” within the health insurance market. This Forum was established following the recommendations of the McLoughlin report.

Health insurers

Private health insurance companies have been developing apparatus to prevent and identify irregularities and fraud. Vhi Healthcare’s dedicated Special Investigations Unit (SIU) and utilisation review process made savings of over €18.5 million in 2015, the company informed MI. The SIU, which investigates incorrect or inappropriate billing, has recovered nearly €60 million since its creation.

The most common “anomalies” identified in 2015 were: incorrect accommodation fees being invoiced by the hospital (for example, where a patient is billed for a private room when the patient has occupied a semi-private room); inappropriate lengths of stay; charges being raised for cancelled procedures; and inappropriate invoicing for certain specified drugs, tests and prostheses.

The SIU has evolved over recent years, according to Vhi’s Healthcare’s spokesperson. It has become “more focused and strategically organised” to identify, investigate and recover monies paid out due to fraudulent practices or incorrect or inappropriate invoicing of claims by healthcare providers. 

Methods used to identify these monies include “stringent billing audits, thorough follow-up on customer queries and other targeted initiatives”. The SIU works closely with the company’s Data Analytics Team in the identification of fraudulent claim trends and abnormalities, and invested further in this area in 2015. 

“We have also put in place a robust investigation casework management system to ensure we can identify and investigate any potential issues at the earliest possible opportunity. In addition, in recent years we have added more medical personnel to the SIU team and we now have medical advisors and clinical nurse specialists to analyse claims, review medical notes and identify instances where Vhi may have been inappropriately billed.”

Vhi Healthcare adopts a “proactive approach” to ensure that claims submitted are robustly scrutinised at every step of the claims process to minimise and prevent inappropriate payments, said its spokesperson.

 “An increase in pre-payment and post-payment validation calls have also delivered additional savings over the past number of years. The ultimate aim is to change behaviours to such an extent that only valid claims are submitted for payment in the first instance. 

“We do believe that the SIU is having a noticeable impact in this area, as the level of inappropriate billing has fallen in a number of areas we have targeted for benefit recoveries and we are also seeing hospitals proactively identifying instances of inappropriate billing or over-charging. In those instances, we have worked closely with the hospitals in question to put in place corrective actions to prevent recurrence of the same issues.”

NI agency investigated ROI patients

Over the course of 2015/2016, CFPS in Northern Ireland investigated 105 cases where individuals were suspected of being resident in the Republic of Ireland, but were accessing free healthcare treatment in Northern Ireland by allegedly providing false information.

The total number of cases for 2013/2014 and 2014/2015 combined was 387. A spokesperson for the service, which is part of HSC Northern Ireland, told MI that it only holds data “on access to GP services within the primary care area”.

According to the CFPS Performance Report for 2015/2016, a new electronic screening process was introduced to detect fraud/error in patient registrations. “Some 35,000 patients were screened, resulting in 254 individuals being referred for deduction from the NI GP register. The projected savings to the HSC are estimated to be in the region of £2.6 million over the next five years,” stated the report.

The CFPS, which has staffing of 29, works across four main areas: fraud investigations; fraud prevention and awareness; fraud detection and data analytics; and probity and exemption within primary care.

Its staff includes accredited counter-fraud specialists and experts in data analytics. “The key area moving forward is data analytics,” said its spokesperson.

In the periods 2014/2015 and 2015/2016, the CFPS team was asked to investigate two medical practitioners and neither were referred to the UK’s General Medical Council.

The CFPS has not had any contact from the HSE or hospitals in the Republic of Ireland for consultancy/expertise purposes.

However, it is currently working on the development of a Memorandum of Understanding (MoU) with the HSE. The CFPS already has a MoU in place with the Department of Social Protection.

Audits

Vhi Healthcare’s SIU conducts targeted audits across the medical provider network each year, where it focuses on a particular area such as prostheses, drugs, blood work, etc, and examines all of the claims in these areas for any “anomalies” in claims patterns or trends. 

“Where an error has been identified, Vhi notifies the provider in question and deducts the monies involved directly from them. The provider is also asked to ensure that their processes are amended to prevent any recurrence. If there are a number of queries or repeat occurrences of anomalies with a particular hospital or service provider, an audit is conducted to identify the extent of the practice, the level of monies to be repaid to Vhi, and the redesign of processes to prevent any reoccurrence of inappropriate billing.  

“In addition to recovering the money involved in any instances of incorrect billing, we also include penalties (fines), interest and investigation costs, thereby adding a financial cost to the offender, which sends a strong message that there are consequences to their actions and activities. Where cases of fraud are detected, they are escalated to An Garda Síochána for further investigation.”

Laya, Ireland’s second-largest health insurance provider, has a team of clinical personnel and business analysts working on its “medical costs management programme”.

“The programme is designed to review practices and efficiencies in hospitals and other healthcare facilities, with the overall aim of delivering best patient outcomes and care pathways for our more than half a million members,” a Laya spokesperson told MI.

“Our clinically-led utilisation review initiative operates in line with international best practice and the multidisciplinary team focus on identifying, investigating, recording, recovering and protecting Laya healthcare against inappropriate billing and other anomalies.”

According to the spokesperson, its process involves the use of visual data analytical software that allows it to analyse claims data and identify any “anomalies” in the system in a simple and straightforward format.

“This process, coupled with medical opinion and expertise, is the primary source for identifying anomalies. We speak with our members in advance of claims payment to ensure that members received the treatment that is billed.”

Among the “anomalies” that it has seen are incidents of upcoding, incorrect use of procedure codes, incorrect pricing issued on an invoice, incorrect application of a provider contract, duplicate billing of procedures and incorrect or over-utilisation of treatments and tests.

“We do not comment on specific cases or incidents in relation to the findings from our medical costs management programme. However, when we commenced the programme in 2012, we estimated that it would result in total savings of €100 million in the four years to the end of 2016 and we are on track to meet this target. 

“Our efforts remain patient-focused and savings achieved are reinvested in initiatives such as our unique CareOnCall offering with online GP consultations and in-home healthcare options, allowing members to be treated in their own home, which has a positive effect on the patient’s care pathway.”

To help identify or prevent “anomalies and inappropriate billing” in the healthcare system, Laya’s recommendations include developing and adherence to efficient patient care pathways to reduce unnecessary admission and eliminate unnecessary extended length of stay in hospitals.

“We would also recommend detailed documentation relating to the procedure performed, length of stay and cost of drugs, as well as the detailed completion of the claims form. We will continue to involve our members in the claims assessment process to ensure they have received the treatment that has been claimed. We will also continue to work with our healthcare partners to develop relationships that ensure mutual transparency, as Laya healthcare remains committed to ensuring that our members receive the best clinical outcome in the most appropriate setting.”

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