Healthcare fraud is a silent epidemic that costs the healthcare industry in Kenya millions annually. It comes in many forms; unauthorized patient services, duplicate billing, false eligibility, and identity theft are just a few examples. To identify if there is potential for fraud in your organization, ask yourself these questions: Are there opportunities for someone to take advantage of us? Are bribes or threats capable of swaying our employees? Could there be unmonitored access to sensitive information? If you answered yes to any of these questions, you’re not alone. All industries are susceptible to fraud.

However, in Kenya, the rate of healthcare fraud remains high, posing a significant risk for local insurance companies and patients. It is vital to be aware of the signs of healthcare fraud so that you do not become an accessory to the crime. Keep reading to find out more about preventing healthcare fraud in Kenya as an insider’s guide.

Healthcare Fraud

Healthcare fraud is not a victimless crime. It can raise health insurance premiums, expose you to unnecessary medical procedures, and increase taxes. Medical providers, patients, and other parties can commit healthcare fraud by purposefully misleading the healthcare system to receive illegal benefits or payments.

Common Types of Health Care Fraud

Committed by Medical Providers

• Double billing: Submitting multiple claims for the same service
• Phantom billing: Billing for a service visit or supplies the patient never received
• Unbundling: Submitting multiple bills for the same service
• Upcoding: Billing for a more expensive service than the patient actually received

Fraud Committed by Patients and Other Individuals

• Bogus marketing: Convincing people to provide their health insurance identification number and other personal information to bill for non-rendered services, steal their identity, or enroll them in a fake benefit plan
• Identity theft/identity swapping: Using another person’s health insurance or allowing another person to use your insurance
• Impersonating a health care professional: Providing or billing for health services or equipment without a license

Insurance Fraud Involving Prescriptions

• Forgery: Creating or using forged prescriptions
• Diversion: Diverting legal prescriptions for illegal uses, such as selling your prescription medication
• Doctor shopping: Visiting multiple providers to get prescriptions for controlled substances or getting prescriptions from medical offices that engage in unethical practices

Prescription Medication Abuse

Creating or using forged prescriptions is a crime, and prescription fraud comes at an enormous cost to physicians, hospitals, insurers, and taxpayers. But the greatest cost is a human one—tens of thousands of lives are lost to addiction each year. Protect yourself and your loved ones by following this guidance:

• If you are taking opioids, take them exactly as prescribed by your doctor, ideally, for the shortest amount of time possible.
• Never share your medication with others.
• Explore non-opioid options with your doctor.

How to curb healthcare fraud in Kenya

1. Train your employees

If your employees understand how fraud can happen, they are more likely to spot it when they see it happening. Fraudulent activity often goes unnoticed because employees either don’t know what to look for or they are afraid of reporting it. When it comes to healthcare fraud, there are two types of employees to be aware of; the unwitting accomplice and the malicious actor.

• The unwitting accomplice doesn’t intend to commit fraud but may have limited knowledge of company policies. It’s important to make sure that all employees are aware of proper procedures, such as who to contact if they suspect fraud.
• The malicious actor knows exactly what they are doing and maybe committing fraud because they need the money or have personal issues to deal with. For example, people who have had their healthcare insurance claims denied know that it can take months to be reimbursed, so they might decide to bill the insurance company for services they didn’t receive.

2. Establish a culture of vigilance

Medical insurance fraud thrives in an environment where employees feel like they need to turn a blind eye to fraud, or they’re afraid of getting in trouble if they report it. In order to establish a culture of vigilance, you need to clearly state your expectations and make it clear that fraud of any kind will not be tolerated. You can also assign a fraud prevention officer whose job it is to investigate fraud claims, investigate employee complaints, and help employees report fraud if they see it occurring.

3. Implement an electronic monitoring system

Electronic monitoring systems help you keep tabs on patients and providers as well as payments made to providers. These systems can help you identify duplicate billing, false eligibility, and patient-information discrepancies. There are several types of monitoring systems, including online portals that allow patients to request appointments and submit insurance claims, a software system for provider scheduling and billing, and an integrated system that links all aspects of the business together.

4. Monitor patient behavior

If your patients are behaving strangely, for example, if they are requesting services that seem excessive or inappropriate, there could be a problem. Patients trying to defraud the system may visit providers and facilities more than once a day or use multiple providers for the same service. If you notice this type of behavior, talk to the patient and ask them why they are visiting so many facilities. If they give you a strange response or don’t seem to be able to justify it, they may be committing fraud.

5. Set up a real-time detection system

A real-time detection system scans your data and looks for red flags that could indicate fraud. It can identify duplicate billing, false eligibility, fraudulent identity, and patient information mismatches. It can also help detect prospects that don’t qualify for coverage. These detection systems can be hosted in the cloud or on-premise. They are highly customizable and can be used to identify multiple types of fraud, including healthcare fraud.

Healthcare Fraud usually happens when someone attempts to extort your insurer based on claims that services for which you are insured were offered. Here are some tips from Shimin Insurance Agency;

6. Ask Questions

When you visit an approved health facility, be sure to ask about the diagnosis and prescriptions available. Make sure that the treatment plan you’re receiving makes sense to you if you’re concerned about your health. Ask about the cost of drugs and whether there are alternatives. You’ll avoid paying excessive amounts whenever you visit a hospital if you keep some money on your insurance coverage at all times. If you’re not provided with the services you’re paying for, you’ll have to pay for them out of pocket. If you develop the habit of asking questions, you will not be charged for services that aren’t provided, thereby avoiding monetary loss.

7. Keep your card safe

Someone who impersonates you is someone who uses your medical card without your permission. Someone you know may ask to use your card or someone you don’t know may impersonate you if they gain access to it. The only way to prevent impersonation is to keep your cards safely stored away from theft. To eliminate this risk, you should always carry your medical card with you, so that you can access medical care quickly if you need it.

8. Track your bills.

It’s important to keep track of your bills while you are in the hospital, particularly if you’re in long-term or intensive care. Being aware of your charges enables you to make good decisions and develop contingency plans if necessary. Hospitals are less likely to overcharge you if they are aware of your efforts to keep track of expenditures.

9. Beware of “free” services.

If you’re asked to provide your health insurance information for a “free” service, the service is probably not free and could be fraudulently charged to your insurance company.

10. Check your explanation of benefits (EOB) regularly.

Make sure the dates, locations, and services billed match what you actually received. If there’s a concern, contact your health insurance provider.

11. Compare the different hospital prices.

The last way to prevent fraud is to compare quotes and keep an ear open. It’s not necessarily fraud if you can get a competitive insurance policy, but it still keeps your money where you want it, in your pocket.

Conclusion

Preventing healthcare fraud is crucial for the survival of the healthcare industry. These preventative measures will help you identify potential fraud and hold employees accountable for their actions.