The relationship between the level of knowledge and the likelihood of fraudulent activities among members of the medical scheme industry. This study will investigate knowledge, perceptions and understanding regarding the functionality of medical schemes and the potential for fraudulent activities within the medical scheme industry.
Introduction
Motivation of the study
Moreover, the paternalistic approach is still commonly practiced by some health professionals (Grunloh, Myreleg, Cajender, & Rexhepi, 2018). Patients are not involved, engage and give informed consent to doctors and other healthcare professionals before a final decision is made. However, some healthcare professionals take advantage of the patient's helplessness and use their skills for their own personal gain and not in the patient's best interest.
Focus of the study
This is due to the limited expert knowledge that patients have about their health problems and thus relinquish all power and rely on the doctor to make decisions on their behalf.
Problem statement
The inability to make informed decisions opens an individual up to vulnerability, fear and the opportunity to become a target of fraudulent activities in this sector. Thus, members may become convenient targets for fraudulent activity opportunities. Fraud in the private healthcare sector is a white-collar crime committed by healthcare providers (Ogonbanjo and Van Bogaer, 2014). To the extent that health care systems have invested millions in preventing this criminal behavior of fraud and corruption, perhaps focusing on their members to see if there is a connection between the role of information members have to make informed decisions and the possibility fraudulent activities in this environment.
Research Objectives and Research Questions
Although information is freely available to anyone who needs it through social media, newspapers, television and scheme information brochures, barriers can still be created if the information is not communicated clearly in a language that is easy to understand. Healthcare providers have a legal duty, as determined by the National Health Act, to share learned knowledge with consumers of healthcare services.
Significance of the study
Research Methodology
Limitations of the Research Study
Chapter Outline
In this chapter the results are interpreted and discussed in relation to the research objectives. Recommendations are made based on the findings of the research, the shortcomings identified by the previous literature are highlighted; conclusions are made based on the objectives of the study.
Introduction
The remainder of the study will involve a review of fraudulent activities by either the service provider or member and will highlight the type of fraudulent activities being committed. It eats away at the core of what the healthcare industry is working towards providing affordable healthcare to all citizens in the country (Chattopdhyay, 2013).
The nature of Private Health Funding
Types of Medical Scheme in South Africa
- Restricted Medical Scheme
- Open Schemes
Limited arrangements allow for greater benefit design and structuring of the inpatient medical program. A good example of a limited scheme that resulted in a major shift from public to private healthcare accessibility for low-income government employees is the Government Employee Medical Scheme (GEMS).
Cost Sharing Strategies
- Cost-Sharing Strategies
- Out-Of-Pocket Payments (OOPs)
- Co-Payments and Levies
This amount will then either be the self-payment, the tax or the balance to be invoiced, which must be paid by the member. A fee is a fixed amount that the member must pay at the service point or before a service can begin.
Health Insurance Products
- Gap Cover
- Hospital Cash Back Cover
Information sharing in a multidisciplinary arena
- The Paternalistic Approach: Past practice still endorsed by power driven
- The Patient-Cantered Approach: Putting the patient in the middle of
- The impact of scheme policy wording: Challenges of language
- Unethical Misbehaviours of Healthcare Professionals
All final decisions were made by the doctor on behalf and in the best interests of the patient (Rowe and Moodley, 2013). A patient-centred approach focuses on placing the healthcare needs of the patient at the fore.
Fraudulent activities in the private healthcare sector
What makes members or patients of medical schemes attractive targets for
Routine activity theory is a branch of opportunity theory of crime developed by Marcus Felson and Lawrence Cohen. The focus of the theory is placed on the specific events of the crime and on the perpetrator's decisions. Furthermore, the theory holds that the offender has little or no control over the type of environment and the state of the environment.
Detection of fraudulent activities
At present, the processing of paper claims is now driven by technological advances, where online real-time claims are submitted to the medical scheme (Medicredit, 2017). Saves time and money compared to paper requirements Elimination of potential errors through manual processing. In addition, the cost implications, which obviously go from old-fashioned paper claims to electronic online claims, cannot be ignored.
Implementation of a Universal Healthcare coverage system (National Health
Nationalization of the health system would promote equity, availability of resources, availability of services and medicines, and adequate delivery of services. Therefore, the introduction of NZZs will cause a shift in favor of the less privileged due to the accessibility and availability of such public ones. The NHI aims to provide a unified healthcare system in South Africa that should recognize socio-economic injustices, imbalances and inequalities in order to improve the quality of life.
Chapter Summary
The aim is to promote a spirit of cooperation and shared responsibility between public and private health providers or professionals, which would also include the exchange of information and knowledge. Capitation is the payment method to be adopted in the new NHI in South Africa.
Introduction
Aim of the Study
Do members of medical schemes have an understanding of scheme penalties and legal requirements as a member. Is there a relationship between the level of knowledge members have about medical schemes and the level of knowledge about opportunities for fraud.
Research Paradigm
This research should follow the quantitative research paradigm, which is also known as the positivist paradigm, where the researcher wants to set an objective as a measure of the topic. Realism is an ontology within this quantitative paradigm that seeks truth, holds beliefs about reality or perspectives of reality, i.e. determines the truth to be discovered. Using the components of the positivist paradigm, the researcher will determine the perceptions, attitudes, and level of knowledge of the participants in accordance with the research question.
Research Design
Research Methods
Research Setting
Population
The term research population refers to a large collection of people whose thoughts, ideas, and behaviors are to be investigated in order to gather responses for the study (explore.com). Sekarand and Bougie (2013), describe a population is a collection of events or people that are of interest to research, for research purposes. Therefore, only individuals in the Johannesburg region would be eligible to participate in the study.
Sample Size and Sampling strategy
Due to the large number of employees (more than 800, wrhi.ac.za) at Wits RHI and Medirite Pharmacies (more than 160 pharmacies, shopriteholdings.co.za), it was challenging to recruit all the employees, across both companies.
Recruitment of Participants
Administration of Questionnaire
The questionnaire was sent by email for wider, easier distribution among participants and participants also collected the paper version of the questionnaire from the researcher themselves. Participants were given 3 days to answer all questionnaires and return them to the researcher. Any doubts or issues arising from the investigation can be answered and resolved immediately.
Construction of the Instrument
The questionnaire was designed using key terminologies used by health scheme advisers on a daily basis to familiarize the participant with these important terms. The inclusion of questions about scheme rules, penalties and the legal aspect of the scheme was intended to familiarize the participant with scenarios that may lead to the application of scheme rules, penalties and legal consequences.
Data Collection
Data Collection Instrument
Data Collection Procedure
Analysis of Data
Validity and Reliability
Validity
Reliability
Research Bias and Elimination of Bias
Sample Selection Bias
In this type of bias, the outcome of the sampling technique may be affected by the exact type of participants the researcher wishes to recruit. These participants would be in a better position to provide the kind of answers the researcher is looking for, to influence his study (Sekaran and Bougie, 2013). This bias can be avoided by setting clear requirements for the participants the researcher wishes to recruit and that the target population will fulfill the research objectives.
Investigator Bias
In this study, the researcher recruited participants who were employed in a retail pharmacy, handling medical scheme claims on a daily basis. The employment sector in the pharmaceutical industry would have benefited these participants when they provided answers. This study was able to prevent this form of bias by setting a defined set of inclusion and exclusion criteria (surveymonkey.com).
Ethical Considerations
Principle of Ethics
Chapter Summary
Introduction
Demographic Data Analysis
Participant Age Data
This question mainly focused on the different age groups of the participant, so that the researcher will get to know the participants involved in the study. The representation of results on figure 4.2 indicated that the ages of the participants were distributed from the twenties to the fifties. The results showed that the participants in their thirties to mid-forties were the predominant group.
Employment Status Data
It can be seen that Figure 4.3 shows that most of the employed participants were employed.
Level of knowledge about Medical Schemes and Fraudulent Activities
Section B: Membership, Contributions, Benefits
No, according to the Medical Schemes Act 131 of 1998, a person can be enrolled in one medical scheme at a time. It is clear from Figure 4.7 that participants did not have a common understanding of the Medical Scheme Act 131 of 1998 Regulations. Employer subsidy for medical scheme is not a right, but is part of the employment contract.
Section C: Minimum Benefits, Waiting Periods, Late Joiner Penalties
According to the analysis of the responses presented in figure 4.12, it appears that only 30% of the participants answered the question incorrectly. According to the responses reviewed and analyzed, it is evident that of all the participants who responded, the majority of participants indicated that they would write a letter or email to the medical scheme. A MEMBER MAY WRITE A LETTER OR EMAIL ADDRESSED TO THE COMPLAINTS DEPARTMENT OF THE SCHEME A MEMBER MAY COMPLAINT TO THE MEDICAL SCHEME COUNCIL IF THE MEMBER'S COMPLAINT HAS.
Section D: Fraudulent activities in the medical scheme sector
Figure 4.15 shows that a smaller proportion of participants had a significant level of knowledge about membership termination and suspension. Although the healthcare provider's intent is to act in the best interests of the member. As shown in Figure 4.21, the majority of answers indicated that a participant can call the medical scheme anonymously.
Comparison of the Key Elements of Medical Schemes and Fraudulent
Introduction
Contributions, Memberships, Benefit Options
- Contributions
- Employer Subsidized Contributions
- Impact of Employer subsidized contribution on cost sharing methods
- Rebates and Refunding of contributions or remaining funds
- Implications of a dual membership
- When may my scheme terminate or suspend my membership?
- Benefit Options
Scheme Rules
- What are Prescribed Minimum Benefits (PMBs)?
- What is a Designated Service Provider (DSP)?
Medical Scheme Restrictions (Scheme Penalties)
- What are the types of Waiting Periods?
- What is a late joiner penalty?
- Fraud and corruption in the medical scheme industry
- What is misconduct to the medical scheme?
- What is medical aid fraud?
- Which of the following would not be considered as fraudulent activity to
- How has fraud and Corruption found a commonplace in the healthcare
- What are the different types of fraud?
- How can a member suspecting of a fraudulent activity alert the scheme? 76
Introduction
This chapter brings the entire research to an end, through recommendations made in relation to the objectives of the study. This chapter also looks at the limitations to which the study was subjected during the course of the study.
Conclusion
These recommendations have been compiled to help medical program companies and healthcare professionals devise methods to enhance patients' healthcare knowledge levels. However, participants had lower levels of knowledge about elements such as benefit options, medical plan rules, contributions, and medical plan restrictions. To investigate whether members are aware of the possibilities of fraudulent activities within the medical insurance industry.
Recommendations
- Investment
- Level of information, language and terminology provided by the scheme
- Level of knowledge and information shared with members or patients
- The impact of fraudulent activities
- Antidote for factious claims (by healthcare providers)
Health professionals should therefore ruminate on sharing patient-specific medical information with the patient in question; give the patient the ability to make their own decisions with the information they have been provided. Throughout the process of disease management, the patient will meet with different service providers with specialist information. It is recommended that all different service providers with whom the patient interacts throughout the disease management process should provide the patient with information regarding the health care problem, before the service provider makes any definitive decisions, therefore the patient should be able to give informed consent. based on sufficient information received from all different service providers.
Limitations of the Study
Recommendations for Future Studies
Position Statement of the American Association and the European Association for the study of Diabetes." Diabetologia Volume 55 Issue. 34; Health Care Consumers' Suspicions of Medical Care Fraud: An Exploratory Analysis." Manocchia Michael, Scott Alyssa, Wang Morgan C. 34; Predicting healthcare fraud: a multidimensional data model and analysis technique for fraud detection. " Thorton D, Mueller RM, Schoutsen, Van Hillegersberg Jos.
