Defrauding National Health Insurance

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September 05, 2016

It is nonsensical to discuss any modifications to the healthcare industry without addressing the existing and future opportunities for fraud. Our readers may question why we are drawing attention to malicious and criminal practices; however, unscrupulous individuals currently defraud the industry of millions of dollars annually.

Fraudulent medical claims directly impact insurance premiums. Our readers deserve to know how it is performed, why it is so costly and why National Health Insurance (NHI) as currently proposed will not only be helpless to stop it, but will likely encourage medical fraud. The NHI proposal neither includes provisions to curb corruption nor accounts for fraud in terms of cost to the taxpayer. Medical fraud is vastly underestimated by the public and simple in practice. To understand the potential for fraud under the proposed NHI scheme, let us delve into current misappropriation practices.

Insurance companies police the healthcare industry in terms of identifying fraudulent claims. These claims can be filed by unscrupulous healthcare providers and patients. Healthcare providers may charge for services not performed, overbill for services or perform procedures that were not medically needed. Some healthcare providers bill patients and customers for the same services at different rates based on the insurance company or if it is paid in cash.

The majority of medical practitioners operate with the highest integrity, ethics and professionalism. Unfortunately, there are a few bad apples who engage in unethical and questionable practices. Insurance companies play a pivotal role in medical fraud risk management by identifying doctors who request reimbursements on procedures and billings that are flagged as being outside the expected range of costs. These doctors are notified and given an opportunity to defend their billing outliers. Should a doctor not provide sufficient reason or evidence for a billing, the insurance provider may choose disciplinary action by banning the medical practitioner from its network and reporting the practitioner to the statutory Bahamas Medical Board.

Now, let us extrapolate this swindling of funds onto the NHI proposal, where the government becomes a public insurer. As proposed, the public insurer will inevitably subsidize policy costs to the detriment of the taxpayer to eventually eliminate the private sector. If by some miracle the private health insurance sector survives, the public insurer will still incur substantial defrauding of the Public Treasury.

We cannot trust the government to be both the administrator and compliance officer. Government self-regulation is an inherent conflict of interest for the Bahamian consumer. How will the Insurance Commission of The Bahamas be able to regulate and discipline a public insurer? Will the public insurer make itself exempt from requirements - i.e., transparent financial records that it cannot meet as stipulated by the commission? Then again, this may not be an issue as it is being proposed that the public insurer will not fall under the oversight of the commission which is responsible for regulating the insurance industry. Rather, it has been suggested that a new distinct government agency with the potential to duplicate some of the commission's supervisory work will be established at a cost to taxpayers to oversee NHI.

How will the government be able to regulate NHI and assure the Bahamian taxpayer that fraudulent claims will be identified, denied and, if needed, prosecuted? If the government administers NHI, chooses its compliance committee and determines prosecutorial action, who protects the Bahamian taxpayer from adversarial political interference and corruption? What if a healthcare provider is overbilling? Will such an individual be allowed to continue if connected to the governing political party?

Bahamians have a right to know that millions of dollars are given unwarranted to individuals defrauding the medical system. What is the government's plan to address corruption in the healthcare industry? Is the government really serious about healthcare reform? If not, what is its real agenda under the guise of NHI?

If the public insurer, as suggested, is to be regulated under a separate agency, where is the accountability and where is the platform for fair competition with private insurance? There are still too many questions and too few answers on the specifics of the government's National Health Insurance plan.

Click here to read more at The Nassau Guardian

News date : 09/05/2016    Category : Health, Nassau Guardian Stories

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