How private clinics, pharmacies are defrauding insurance providers

Rwanda Social Security Board has been on the receiving end of fraudsters’ attempts to swindle funds off them. The practice has often been executed by some pharmacies and clinics that often seek to create extra payments, drive overconsumption of services as well as using fictional prescriptions and bills. The fraudulent practices often involve a combination of practices, some complex and some easier to implement, The New Times has learnt. Among the ‘easy’ practices, The New Times established include prescription of unnecessary medicine and procedures by pharmacies and clinics to present higher bills as well as billing for medical services that were never provided. A pharmacist told The New Times that another practice that has been in existence for years involves an RSSB member visiting a clinic or physician and requesting for a prescription for another person which is then billed to the RSSB beneficiary’s account in the medical scheme. The pharmacist said that in most such instances, the clinics and physicians that are open to the practice are often well known among a section of RSSB’s insurance holders. Other tactics by healthcare service providers include duplicating medical bills from other health facilities and claiming payments from RSSB. This trend was noted when bills and details of the same patient are presented to RSSB multiple times implying that the patient has been treated multiple times while in fact they were only treated once. Those with insights into the subject say that among fraudulent trends that have also emerged include clinics going to schools and colluding with school management to get students with medical insurance to visit their clinic for consultation and treatment. Other clinics also use dubious tactics such as undertaking unnecessary procedures and tests for their patients in an aim to drive up consumption and drive up medical bills. Another pharmacist said that they have previously come across cases of clinics conducting pregnancy tests on women who are well past the menopause stage in a bid to drive up the consumption. The vulnerability has been said to be among other things a result of the current system and procedures of interaction between RSSB and service providers. These observers say leaves much room for RSSB agents in clinics and hospitals to be corrupted as well as a number of fraudulent practices to go by unnoticed. On their part, RSSB officials say that among the most common practices they have noted include swapping of membership cards by patients to give medical benefits to a non-eligible person as well as service providers ignoring standards of professionalism for the purpose of benefiting from extra payments. The agency noted that other common tactics observed include fictional prescriptions and bills “Overpricing and overbilling of medical benefits, billing for multiple procedures that are covered in a single one procedure, billing for services not provided,” the agency said. Regis Hitimana, the Deputy Director General in charge of Benefits at RSSB told The New Times that they have established that the vulnerability to fraud is heightened by lack of automation from the check-in and the check-out points, as well as the billing processes, lack of sufficient and trained staff to conduct necessary analyses, monitoring and medical inspections. “Vulnerability has also resulted from insufficient use of data in fraud control and lack of fraud detection tools,” Hitimana added. Hitimana said that beginning June 2019 to date fraud amounting to Rwf73,664,210 had been detected and processed in RSSB’s two health insurance schemes. However, some of the cases were related to invoices for the period before July 2019. He, however, clarified that the amounts reported are only a ‘tip of the iceberg’ as it is estimated that a significant portion goes undetected. “Detecting and qualifying the act as fraud is not an easy process and the capacity and means used are not up to the size of the problem,” he added. However, RSSB is in the process of putting an end to the practices following the oncoming IT modernization which cut out any vulnerabilities and gaps. The process expected to kick off in the coming financial year, he said will be tailored to address challenges without complicating use by patients. Hitimana said that among ways members of the public can play a role in curbing fraud include avoiding the exchange of their membership cards with non-eligible beneficiaries, checking and seeking clarification before signing on their medical bills. The concerns of fraud at RSSB are not a new subject. Last year, it emerged that health care costs were not proportionate to contributions to the scheme. For instance, in the first six months of 2019, the expenditure was estimated at Rwf54.2bn which is about 14 per cent more than had been projected. The projections were set at Rwf47 billion for the 6 months period. The board has previously expressed intentions to adopt fingerprint or facial recognition technology as a replacement for health insurance cards for all subscribers to curb fraud. This would among other things curb instances of swapping membership cards as well as fictitious invoices.

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How private clinics, pharmacies are defrauding insurance providers