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News... Insurance News Doctors call for calm ahead of fraud database launch
News... Insurance News Doctors call for calm ahead of fraud database launch | Doctors call for calm ahead of fraud database launch |
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Hospital consultants have asked private medical insurance (PMI) providers to take a more measured approach when investigating potential cases of fraudulent billing by doctors. The request comes as Britain’s PMI providers put the finishing touches to an industry-only database which will list customers and doctors who they believe have committed fraudulent activity, Health Insurance can reveal. While insurers insist that they are operating in the best interests of their customers – and that fraud is very rare among the medical profession – doctors’ representatives are worried that there are many “grey areas” in medicine which could leave consultants open to unfair accusations of fraud. Last month saw the conclusion of an anti-fraud investigation – believed to be the most extensive one of its kind – carried out by the General Medical Council (GMC), the doctors’ regulator, at the request of a number of insurers. The GMC ruled that a hospital consultant had carried out so-called “upcoding”, the process whereby doctors charge too much for their services, and subsequently suspended him for 12 months, pending an appeal. While not commenting on that specific case, Geoffrey Glazer, chairman of the Federation of Independent Doctors’Organisations (FIPO), said that some insurers’ processes mean that it is difficult for doctors to assign the correct billing code to procedures which they carry out. As a result, the “majority” of claims suspected to be fraudulent are in fact due to “routine complications and variations in treatment” that lead to coding changes required by an individual patient’s condition. Glazer told Health Insurance: “Insurers have to accept that not all cases can easily fit into the rigid codes that are required to be submitted for each procedure and that many changes from pre-authorisation or errors are quite genuine.” However, Dr Simon Peck, head of provider information and audit at AXA PPP, Britain’s second largest medical insurer, said that insurers are stepping up their efforts to detect fraudulent behaviour by doctors which, while not widespread, is “financially significant” and is pushing up the cost of PMI. AXA PPP recovered more than £1m from misbilling by doctors in 2007 and will continue to investigate suspected cases of fraud, he said. [Editors Note] Some of those efforts will be channelled through the Health Insurance Counter Fraud Group, which counts among its other members Norwich Union Healthcare and PruHealth , Dr Peck continued. Although an industry-only website is soon to be launched offering approved organisations access to a database of doctors and customers suspected of fraud, providers remain keen to find ways of dealing with suspected bad practice without having to take matters to the GMC, Dr Peck added. However, Glazer said FIPO members want to see the creation of a different, independent body to assess more complex cases and act as mediator where claims are questioned. He said: “To truly eliminate PMI fraud, insurers need to recognise that there is no one-size-fits-all approach to medicine and make the necessary effort to assess some claims individually. That way they can identify the few cases of real fraud.” Link: http://www.hi-mag.com/healthinsurance/ Credit: Health Insurance Magazine. May 2008 Other Useful Links: FIPO (Federation of Independent Practitioners): http://www.fipo.org.uk/ ABI (Association of British Insurers): http://www.abi.org.uk/ |
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