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South African Dental Journal

versão On-line ISSN 0375-1562
versão impressa ISSN 0011-8516

S. Afr. dent. j. vol.73 no.9 Johannesburg Out. 2018

http://dx.doi.org/10.17159/2519-0105/2018/v73no9a1 

RESEARCH

 

Dental fraud in South Africa 2007 - 2015

 

 

R PutterI; S NaidooII

IBChD(UWC), MSc (UWC), Department of Community Dentistry, University of the Western Cape, Tygerberg
IIBDS(Lon), LDS.RCS (Eng), MDPH (Lon), DDPH. RCS (Eng), MChD (Comm Dent), Emeritus Professor, Department of Community Dentistry, University of the Western Cape, Tygerberg

Correspondence

 

 


SUMMARY

Healthcare fraud wastes money properly allocated to patient treatment, and the extent, never researched, is difficult to determine, especially in the South African two-tier healthcare system. A retrospective, record-based study aimed to determine these data between 2007 and 2015.
Data were sourced from the Health Professions Council of South Africa (HPCSA), from Discovery and from the Board of Health Care Funders (BHF). Cases against dentists and dental specialists at the HPCSA peaked in 2013 with 22 cases, while dental therapists faced 12 cases in both 2009 and 2014. While there is a gradual decrease in the number of fraud cases, the amounts involved are increasing.
Discovery revealed that fraudulent cases involving dentists have decreased from a high in 2007 with 179 cases to 63 in 2015, with total fraud just more than ZAR13.6 million. Cases involving dental therapists have increased from 1 in 2007 to 22 in 2015. The total for all dental professionals at Discovery was ZAR18.1 million. BHF estimated that ZAR 40 million was lost to dental fraud over the nine year period Dental fraud appears to be on the increase. It seems that dental therapists have a higher incidence than amongst dentists or dental technicians.


 

 

INTRODUCTION

Fraud is not a new phenomenon and is not limited or confined to certain countries, governments or even specific industries. It is however more prevalent in some countries than in others, affecting developed as well as resource-poor countries.

Most countries aim to diminish crime, fraud included; yet there is a stoical awareness that it is unlikely that a crime-free society will ever be achieved. Policing can, however, try to make it as difficult as possible to commit crime, and in this case, to commit fraud or to indulge in fraudulent activities.

The healthcare industry is unique in that it has many different role-players: government, large private companies including hospital groups and insurance companies (called medical aid schemes in South Africa), private healthcare practitioners and consumers, and is both a service- and product-based industry.

This results in a very complex industry where vast amounts of money are spent while at the same time there are too many role-players vying for their own personal gain. Inevitably, some take advantage of the system and manipulate it to their benefit.

Very little research has been done on healthcare fraud and specifically dental fraud in South Africa. Even though medical aid spending on dentistry forms only a relatively small part of the healthcare industry in South Africa, millions of rands are at stake, offering a viable market for healthcare fraud.

With the general public complaining of the high cost of and steep inflation in healthcare, fraud detection and prevention in the industry should be of paramount importance for governments, politicians and policy makers. The purpose of the present study was to estimate the levels of dental fraud and the amounts involved, in South Africa. As with many other crimes, it is nearly impossible to determine the exact amount of dental fraud in the country.

An estimation can be calculated by using international standards and averages in relation to the total amount of healthcare expenditure. One method is to review the fraud cases documented by the Health Professions Council of South Africa (HPCSA) as well as examining fraud cases from individual medical aid schemes or administrators in South Africa. However, Gee et al. (2010) have shown that this will represent an under-estimate of the amount of fraud.1

Detected cases of fraud do not of course represent the total number of fraud cases. According to the HPCSA, all cases of fraud in excess of R100 000 should be reported to the South African Police Service (SAPS), but it is not possible to obtain any data from the SAPS.2

Since there is a paucity of research in this area, a nine year retrospective study (2007-2015) on dental fraud was carried out. It was anticipated that the review would assist in the development of guidelines to help prevent dental fraud in the future.

The World Health Organisation (WHO) has re-iterated the fact that one can never eradicate the dishonest minority that commit healthcare fraud, but, by developing and implementing a strong anti-fraud culture, the number of the honest and ethical health practitioners can be increased.3

Improving the character of a nation instead of writing and implementing more rules, may eventually result in a decrease in fraudulent crime.

 

DEFINING FRAUD AND HEALTHCARE FRAUD

Fraud can be defined as the wrongful deception, misrepresentation or concealment with the clear intention to deceive, resulting in personal or financial gain, or as intentional theft.4-6

Vian (2008) described corruption as the misuse of power for personal or private gain, and also noted that definitions for corruption vary from country to country, and may even be different within areas of the same country.7

Busch (2012) defined healthcare fraud as the deliberate practicing of a scheme or programme to defraud a healthcare scheme or attaining money or property by means of false undertakings, representations or deceptions.8

Fraud is not the same as abuse. Hannigan (2006) reported that fraud implies an intention to be dishonest whereas abuse does not, and Busch (2012) defines healthcare abuse as substandard care.8,9 Hannigan (2006) goes further to state that although abuse does not imply intent, it is not excusable on the basis of ignorance.9

It is clear that there is no perfect or uniform definition for fraud. The most difficult part when dealing with fraud is proving intent.10 Many fraudsters claim ignorance and often receive a lesser punishment for abuse, rather than being labelled as an intentional fraudster, which in most healthcare systems carries a far more severe punishment.

 

HEALTHCARE FRAUD IN SOUTH AFRICA

A survey conducted by KPMG in which several of the largest medical aid schemes in South Africa participated, reported 11 200 cases of fraud for the three year period 2007 - 2009.11 The rand value of these fraud cases exceeded ZAR221 million.

This was the third survey of its kind done by KPMG and even though the figures are very high, they have documented a downward trend in both the number of fraudulent cases per year as well as the value of these cases over nine years.11

Discovery Health recovered more than ZAR250 million from fraudulent claims in that three year period.12 It must be noted that, with roughly 84% of the total population in South Africa not medically insured, a vast amount of healthcare fraud would not be included in these figures.

Statistics released by the Board of Healthcare Funders (BHF) recently reported healthcare fraud in South Africa to be approximately R22 billion annually, although when applying the international average of 7% of claims paid, it is estimated at between R3 billion and R15 billion annually.12

Kahn (2014) recently reported estimates of between R8.22 billion and R42.2 billion.13 The Health Professions Council of South Africa (HPCSA) published figures for healthcare fraud estimates at between R4 billion and R15 billion, while the WHO at the same time reported healthcare fraud in South Africa to amount to between R4 billion and R8 billion annually.2,3

The 2013-2014 annual budget for healthcare expenditure in South Africa was R133.6 billion.14 The estimate of R3 billion - R15 billion fraud would equate to 2.25% -11.23% of that annual budget. This is in line with worldwide estimates when compared with annual healthcare budgets in the United States and Europe.

It does not, however, mean that this is an acceptable figure. The figures released by KPMG are much lower when compared with other estimates of the situation in South Africa, and this could be due to the fact that the KPMG report investigated fraud at the medical scheme level, and only around 16% of South Africans are medically insured.11

As can be gleaned from the discussions above, the figures for fraudulent activities are all estimates with a wide range of values. The WHO confirmed the absence of accurate data in a recent report.3 A frightening statistic though, shows healthcare fraud to be on the increase in South Africa.15

 

DENTAL FRAUD IN SOUTH AFRICA

No statistical data could be found specifically for dental fraud cases in South Africa, although Postma et al (2011) published data regarding complaints against oral health professionals in South Africa.16

Fraud was one of the categories under which complaints were reviewed. Postma et al (2011) reported 30 fraudulent cases between 2004 and 2009, which added up to 29% of all complaints against dentists.16 For dental therapists 12 cases of fraud were reported between 2004 and 2009, resulting in 46% of the total number of complaints against dental therapists.16

It was also noted that the fraud-related complaints generally arose due to the irregular accounts that were sent to patients and/or irregular submissions to medical aid fund administrators.16

According to a report published by KPMG nearly 70% of all healthcare fraud consists of charging for services not rendered and code manipulation.11

Unfortunately these figures do not provide a complete picture of the amount of dental fraud in South Africa. The cases were only those investigated by the HPCSA, and where practitioners were found guilty. Many fraud cases never reach the HPCSA and are either resolved at patient-practitioner level or at the medical aid administrator level.

 

COMMON HEALTHCARE FRAUD TYPES IN SOUTH AFRICA

Postma et al (2011) reported on the following types of fraud, which they found in the misconduct records of the HPCSA:

over-servicing, over-charging, claiming for services rendered to non-members, changing service dates, discrepancies between clinical records and billing records, submitting claims whilst suspended from practicing, incorrect tariff codes, claiming for procedures not performed, split billing and claiming for non-claimable goods. Unfortunately, these HPCSA data do not reflect the exact amount of fraud in each type.16

The triennial KPMG survey found code manipulation to represent 39.81% of service provider fraud cases between 2007 and 2009.11 This was followed by: charging for services not rendered (25.32%).

These two alone made up nearly two thirds of the total number of healthcare fraud cases and showed an increasing trend in the number of code manipulation cases. Service provider fraud totalled ZAR151.9 million while member fraud came to ZAR67.3 million.

Ogunbanko et al (2014)15 compiled the following list of the types of healthcare fraud committed in South Africa:

Service provider fraud

Pharmacies dispensing generic medication but claiming for expensive brand-name medication.

Pharmacies selling front-shop items but submitting claims for medication that is not dispensed.

Pharmacies selling high-cost devices in surplus of the needs of the member.

Claiming for services not rendered.

Service providers willingly treating non-scheme members but claiming as if treating a scheme member.

Dispensing doctors dispensing generic medication but claiming for expensive brand-name medication.

Fraudulent sick notes.

Providing cosmetic treatment but claiming for some other covered procedure.

Changing of diagnosis to access a specific benefit.

Claiming for excessive or additional material not used during treatment.

Dentists claiming for additional Allings or extractions that were not performed.

Dentists providing cosmetic gold inlays but charging for normal crowns.

Bio-kineticists acting as personal trainers to healthy members in gyms but claiming for rehabilitation services.

Member fraud

Forging and submitting claims for procedures that were never rendered.

Claiming for high-cost equipment, receiving the money, but then failing to pay the supplier and not collecting the equipment.

In collusion with doctors and hospitals claiming for false hospital admissions.

Sharing of medical scheme membership card with non-scheme members.

Fraud by other individuals or syndicates

Submission of false membership applications and submitting claims for those false memberships.

Falsification of bank details to receive payment instead of members of service providers.

Admission of healthy members to hospitals in order to benefit from hospital cash-back insurance.

Syndicates colluding with employees of healthcare funders.

Brokers providing false information to avoid waiting periods and late joiner penalties.

Discovery reported on the following types of healthcare fraud in South Africa:

Claiming for services not rendered

Merchandising

Claiming for non-covered benefits as a covered benefit

Cash Loans (ATM scams)

Card Farming

Cosmetic Surgery

Code Gaming or Manipulation

Non-disclosures

It is clear from this list that perpetrators are always finding new and creative ways to commit fraud in the South African healthcare system.

Healthcare fraud wastes money that could be spent better in the management of patients. The exact amount of healthcare fraud is very difficult to determine, especially in a two-tier healthcare system like South Africa.

The amount and cost of dental fraud in South Africa has never been researched. If the amount and cost of fraud in a specific area can be determined, resources can be better used to combat healthcare fraud in the future.

The present study design was a retrospective, record-based study. The study protocol was submitted for ethical approval and approved by the University of the Western Cape Faculty and University Research Ethics Committee.

Confidentiality was maintained at all times The number of dental fraud cases which had been recorded in South Africa over a nine year period was determined, and where possible, the value of the fraud in each case was calculated. The number of cases per dental professional was calculated to provide a picture of the overall level of fraud in the profession.

Data was accessed from the HPCSA website on which is published annually a list of completed cases against healthcare practitioners. Discovery provided data from a number of Medical Aids, after having sought the permission from the individual schemes. At no time was any personal information regarding patients, the practitioners or the individual Medical Aid discussed or recorded.

Contact with other Medical Aid schemes was attempted, but the enquiries were repeatedly referred to The Healthcare Forensic Management Unit (HFMU) of the Board of Healthcare Funders (BHF). That Unit responded to the request and provided relevant data without any personal information regarding patients or practitioners.

The collected data from the HPCSA, Discovery and the BHF were recorded and captured on a Microsoft Excel spread sheet. The data varied considerably between institutions and were not readily comparable due to differences in the interpretation of fraud and fraud categories, and therefore no further statistical analysis was carried out on the data.

 

RESULTS

The lists of cases published annually by the HPCSA include procedures conducted against all healthcare professionals registered with the HPCSA and are not limited to fraudulent activity.

Dental professionals registered with the HPCSA include dentists and dental specialists, dental assistants, dental therapists and oral hygienists. Cases of abuse are included with the fraudulent cases reported by the HPCSA. Some practitioners had more than one case registered and in the present study each was counted separately.

Response rate

The HPCSA data was available only from 2007 onwards. Discovery submitted data for all medical schemes that falls under their administration, which constituted just more than 1.2 million insured lives. The BHF were only able to obtain permission and data for 40% of the Medical Aid schemes registered with them.

These did however include the dental administrator DENIS as well as Medscheme. A lack of manpower at BHF prevented their providing data on the number of cases per practitioner. The actual number of cases might thus not give an accurate representation of the extent of fraud.

HPCSA finalised cases (2007-2015)

The reported HPCSA cases between 2007 and 2015 are shown in Table 1. Cases are shown for dentists and dental specialists together, as the HPCSA makes no differentiation between general dental practitioners and dental specialists.

Table 2 shows cases against dental therapists for the same period. There were no cases reported against oral hygienists or dental assistants and dental technicians are not registered with the HPCSA.

It should be noted that these Tables reflect only those cases where the HPCSA found the dental professional guilty, and are not an overall list of all the cases handled by the Council. Cases were categorised into fraud, clinically related, employment of unregistered person(s) or laboratory, poor record keeping, billing/price, incorrect advertising and unlicensed equipment.

Figures 1 and 2 are graphical representations of the fraud cases against dentists, dental specialists and dental therapists between 2007 and 2015 respectively.

 

 

 

 

Cases against dentists and dental specialists at the HPCSA reached a crescendo in 2013 with 22 cases. The majority of the fraud cases (19) in 2013 were

committed by a single practitioner. The same practitioner was also responsible for 47 guilty charges of employing an unregistered laboratory/person. In 2014 a single practitioner was responsible for half of the fraud cases.

The data for dental therapists is very different from that of the dentists and dental specialists. Cases against dental therapists reached a maximum in both 2009 and 2014 with 12 cases. In between those years the cases dropped to zero in 2011.

The total number of dental fraud cases can be seen in Figure 3. The linear trend shows a gradual increase in dental fraud for all dental professionals in South Africa according to HPCSA data between 2007 and 2015. Due to the numbers being small and easily overshadowed by one or two practitioners with a large caseload against them, it is difficult to track the trends for fraud per dental professional.

 

 

Discovery cases (2007 - 2015)

The number of dental fraud cases per dental professional as found on all Medical Aid schemes under the administration of Discovery between 2007 and 2015 are shown in Table 3, and Table 4 shows the value in South African Rand of those cases. Data are shown for dentists and dental specialists together, as Discovery makes no differentiation between general dental practitioners and dental specialists. There were no cases reported against oral hygienists or dental assistants.

Figures 4, 5 and 6 show graphical representations of the number of fraud cases for dentists, dental therapists and dental technicians individually between 2007 and 2015. Figures 7, 8 and 9 show the value in South African Rand of those fraud cases.

 

 

 

 

 

 

 

 

 

 

 

 

The Discovery data show three distinct patterns for each dental profession. The overall picture for the dentists shows a gradual decrease in the number of fraud cases, although the actual ZAR values are still increasing. The number of fraudulent cases involving dentists as investigated by Discovery decreased from a high in 2007 with 179 cases to 2015 with 63 cases.

Fraud by dental therapists showed a remarkable increase in both the number as well as the value of cases. The incidence increased from 1 in 2007 to 22 in 2015. The number of registered dental therapists is just more than 10% of the number of registered dentists in South Africa on a yearly basis, yet the value of fraud for dental therapists is nearly 25% that of the dentists. The dental technicians showed very little fraud, except for a larger caseload in 2012 and 2013. Dental technician cases started at 1, climbed to a maximum of 134 in 2013, then decreased again to 2015 with 2 cases.

Data from Discovery reveals a total value of the fraudulent cases involving dentists from 2007 to 2015 to be just more than ZAR13.6 million, whilst the total for all dental professionals for the same time period was ZAR18.1 million.

BHF Cases (2007 - 2015)

Table 5 shows the number of dental fraud cases per dental profession as found in the BHF collated data between 2007 and 2015 and Table 6 shows the value in South African Rand of those dental fraud cases per dental profession.

Cases are shown for dentists and dental specialists together, as the BHF makes no differentiation between general practitioners and dental specialists. There were no cases reported against oral hygienists or dental assistants.

Figures 10 and 11 show graphical representations of the number of fraud cases for dentists and dental therapists respectively between 2007 and 2015, whilst Figures 12 and 13 show the value in South African Rand of those cases.

 

 

 

 

 

 

 

 

Between 2011 and 2013 the BHF underwent a change in the fraud detection system, resulting in very few cases being recorded during that period.

Unfortunately the BHF were unable to provide data for 60% of all the medical aid schemes that are members of BHF, and the number of fraud cases does not take into account more than one case per practitioner.

The actual number of fraud cases may therefore be grossly under-estimated. With the changes in the fraud detection systems, very little data exists between 2011 and 2013.

When the value of dental fraud from the BHF data was extrapolated for all their medical aid scheme members, the total was found to be ZAR 21.6 million over the nine year period.

 

DISCUSSION

It is clear from the results of the present study that it will always be impossible to accurately determine the actual amount of healthcare or dental fraud in any healthcare system. The total amount of fraud can be estimated, evidence of the amount of fraud identified or detected can be provided, but figures are often under-estimates. Many patients are victims to healthcare fraud without being aware of it.

It is of considerable concern that dental fraud over a nine year period in South Africa was estimated to be nearly ZAR 40 million. Even this figure is an under-estimate as it does not include the HPCSA data as the Council does not specify the value of the fraud. In addition, fraud appears to be on the increase in most cases.

A recent report by KPMG found that only 0.9% of healthcare fraud in South Africa was reported to the South African Police Service (SAPS) between 2001 and 2009.11 This is a very worrying statistic, especially considering the stance other countries are taking against fraud. As mentioned earlier, the Attorney General's office in the USA listed healthcare fraud as one its most important priorities, second only to violent crime.9 Of course, with the high levels of violent crimes in South Africa it may be easy to argue why human resources are not being used to combat healthcare fraud but rather is being spent on fighting violent crimes.

There is no central database for reporting healthcare or dental fraud in South Africa, and very few cases are reported to the SAPS... or even the HPCSA. This makes tracking the total extent of fraud very difficult.

There is also a lack of co-operation and communication between the individual corporate bodies, necessary if they are to work together to decrease healthcare fraud. This situation is also prevalent in other countries.

Dental or Medical Councils do not report fraud by its members to the other international professional councils. This has been recently illustrated by a case in this country where a South African born dental practitioner was jailed in the UK for dental fraud, but returned to South Africa and has been permitted to continue to practice in the country. When a person is jailed for fraud and prevented from continuing his/her practice in a certain country, it is surely prudent that the authorities be informed.

Many Medical Aid schemes are unwilling to share their data to help combat fraud and this could also be why so little healthcare fraud is reported to the SAPS. Medical Aid schemes spend much time and effort recovering money which has been lost from members due to fraud and once that has been recovered, do not feel the need to report the perpetrators.

Fraud seems to be ever-increasing amongst all dental professionals, but more so with dental therapists. That discipline represents less than 10% of the registered dental professionals with the HPCSA, but fraud committed by therapists accounts for more than 30% of the total amount committed by dental professionals.

 

CONCLUDING REMARKS

One of the main hurdles in the fight against healthcare fraud, not only in South Africa, but also on a global scale, is the lack of communication and co-operation between the different role players. Very few Medical Aid Schemes or administrators share fraud data among themselves, with the HPCSA, and even less with the SAPS. If healthcare fraud is to be reduced, this situation has to change.

It should be a requirement that all healthcare fraud above a certain threshold should be reported to the SAPS as well as to the HPCSA. Practitioners proven to have committed fraud above a certain value should be taken off the Register and at least not be allowed to practice for a period of time. The FDI (World Dental Federation) may be that body which could institute an international register to list practitioners, worldwide, who have committed dental fraud.

Billions of dollars, euros, pounds and rand are lost annually to fraud with no clear light at the end of the tunnel. Prevention could save millions of rand that could be ploughed back into the delivery and provision of healthcare. To achieve this, it is important that all role-players in the South African healthcare milieu take a policy approach of zero tolerance and work together to combat and overcome medical and dental healthcare fraud.

It is important to remember that not all medical and dental professionals commit fraud; the profession is filled with ethical, honest and dedicated men and women. However, while it is only a small percentage of practitioners who commit fraud, the problem is in fact on the increase. Further studies are needed on a regular basis to track changes in dental fraud in South Africa.

 

References

1. Gee J, Button M, Brooks G, Vincke P. The financial cost of healthcare fraud. London: Macintyre Hudson LLP and Centre for Counter-Fraud Studies, University of Portsmouth; 2010. Working Paper.         [ Links ]

2. Health Professions Council of South Africa. (HPCSA). The Good, The Bad, and The Fraudulent: Medical Aid Claims. The Bulletin. 2012; 34-7.         [ Links ]

3. World Health Organization. Prevention, not cure, in tackling health-care fraud. Bulletin World Health Organization. 2011; 89:858-9.         [ Links ]

4. The Concise Oxford Dictionary. 10th Edition. Oxford: Oxford University Press; 1999. Fraud. p. 562.         [ Links ]

5. Merriam-Webster. [Internet] Springfield (MA); Merriam-Webster Incorporated; 2013. Fraud. [cited 2013 Sept 2] Available from: http://www.merriam-webster.com/dictionary/fraud.         [ Links ]

6. Rocke S. The war on fraud and its effect on Dentistry. J Am Dent Assoc. 2000; 131:241-5.         [ Links ]

7. Vian T. Review of corruption in the health sector: theory, methods and interventions. Health Policy Plan. 2008; 23:83-94.         [ Links ]

8. Busch RS. Healthcare Fraud: Auditing and Detection Guide. 2nd Edition. Hoboken: John Wiley & Sons Inc; 2012.         [ Links ]

9. Hannigan NS. Blowing the whistle on healthcare fraud: Should I? J Am Assoc Nurse Pract. 2006; 18:512-7.         [ Links ]

10. Transparency International. Global Corruption Report 2006: Corruption and Health. London: Pluto Press. 2006.         [ Links ]

11. KPMG. Medical Schemes Anti-Fraud Survey [Internet] KPMG; 2012. [cited 2013 Nov 11] Available from: http://www.kpmg.com/ZA/en/IssuesAndInsights/Articles_Publications/General-Industries-Publications/Documents/MC7143%20Anti%20Fraud%20Survey.         [ Links ]

12. Discovery. Fraud in the healthcare industry is costing members of medical schemes a fortune. [Internet] Discovery Health; 2013. [cited 2013 Sept 2] Available from:https://www.discovery.co.za/portal/individual/medical-aid-news-jul13-medical-aid-schemes.         [ Links ]

13. Kahn T. Discovery Health warns fraudulent claims cost SA over R8bn. Business Day Live. [Internet] 2014 May 29. [cited 2014 Jun 15] Available from: http://www.bdlive.co.za/business/healthcare/2014/05/29/discovery-health-warns-fraudulent-claims-cost-sa-over-r8bn.         [ Links ]

14. South African National Treasury. People's Guide to the Budget: English. [Internet] Pretoria 2013; [cited 2013 Nov 28]. Available from: http://www.treasury.gov.za/documents/national%20budget/2013/guides/2013%20People's%20Guide_English.pdf.         [ Links ]

15. Ogunbanjo GA, Knapp van Bogaert D. Ethics in health care: healthcare fraud. SA Fam Pract. 2014; 56(1):Supplement 1.         [ Links ]

16. Postma TC, van Wyk PJ, Heymans JH, White JG, Prinsloo PM. An analysis of complaints against oral health professionals charged with misconduct at the HPCSA: 2004-2009. SA Dent J. 2011; 66(9):420-5.         [ Links ]

 

 

Correspondence:
Renier Putter
57 Albert Street, George.
Tel: +27 (0)44 874 6455 (w)
E-mail: renier@drputter.co.za

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