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Fraud, waste and abuse in the healthcare system

– Discovery making great strides to curb the problem

Discovery Health recently reported that they have invested substantially in fighting the scourge of healthcare fraud, waste and abuse. In 2018, Discovery Health’s efforts to curb fraud, waste and abuse in the healthcare system resulted in a substantial R555m recovered on behalf of client schemes.

Efforts to fight fraud included the deployment of a specialised team of over 100 analysts and professional investigators as well as a proprietary forensic software system that uses continually updated algorithms to analyse claims data and identify any unusual claim patterns. Invaluable tip-offs from whistle blowers also helped to identify fraud, waste and abuse.

Types of fraud, waste and abuse cases identified in 2018 were:

  • Claims submitted for services not rendered (40%)
  • Capturing errors by a practice (16%)
  • Procedural codes applied incorrectly by healthcare providers – e.g. using a code that carries a higher value than the service performed (12%)
  • Outlier trends are identified for a practice – an audit is needed to verify claims (11%)
  • Duplication of claims (6%)
  • Claims by non-members (4%)
  • Claims for more expensive items or items different to those supplied (4%)

Click here to read the media release that shares more about the top offences per region, as well as specific examples of fraud, waste and abuse.

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