Filenews 29 November 2021 - by Marilena Panagi
Only one doctor had submitted in the space of one year, 99% of the procedures submitted by all the other doctors of his specialty for a specific medical activity and this was only one of the cases in which this doctor, as shown by the data of the GHS informatics system, had probably abused the System. Similar is the situation with the registrations of a second specialist doctor, who also seems to have made claims for specific activities at very high rates, against the procedures of all the other doctors of his specialty.
Both, medical experts, received a letter last Friday informing them that the HIO has suspended the validity of their contract and they will remain outside the GHS until the completion of the ongoing investigation against them, without excluding in the end they will be permanently expelled from the System and/or face criminal offenses. As reported by information provided by "F", it follows and continuously since the OSO has put under its microscope other specialists of different specialties who present disproportionate activity with colleagues in the GHS.
As far as the two doctors who have already received a letter suspending their contract are concerned, it is worth mentioning that they belong to the group of doctors who mostly belong to surgical specialties and as "F" published a few days ago, they are alleged to have secured exorbitant amounts for the outpatient services they declared to have offered to the GHS last year. In fact, one of the two had reportedly received more than half a million euros for services in addition to the surgeries he had performed.
In the letter sent by the WHO, and addressing each of the two doctors, he stated:
"The Organization has good reason to believe that you may have carried out acts that constitute fraud, or involve the element of deception or lack of morality and lead to the exploitation of the GHS in violation of the obligations that burden you and which derive from the provisions of the contract and / or the provisions of the General Health System Law. "
Mentioning in detail the "suspicious" cases, which have been identified through the IT system, the OECD informed the doctors that:
"The Agency has decided to exercise its right under the contract between you and the law and to temporarily suspend the contract until the completion of the investigation. Please note that as part of the survey you will be given the right to submit your positions and you will be informed of the result. It is noted that depending on the conclusion of the conducted investigation, the Organization may lift the suspension or terminate the contract, as well as other measures that may be deemed necessary and that concern possible violations of your obligations, as a contracted provider and/or of the natural persons providing care services on your behalf, including informing other competent bodies in case of detection of such violations that may require criminal investigation.
In nine months submitted greater demands than all doctors
In the first specialist doctor, the OSO analyzes its own data, as they result from its entries in the GHS informatics system:
"In particular, the Agency, in the context of an ex officio investigation, has found that during the period January to September 2021, you have registered in the IT system a number of specific activities much greater than the total number of activities registered by all the contracted with the Organization (doctors of the specialty). Taking into account the above actions, the Organization has good reason to believe that you may have registered in the system information activities and have submitted corresponding requirements which:
- They do not concern medically necessary health care services and/or
- These are activities which have either not been carried out in their entirety, or some of them have been carried out."
In particular, "the Organization has good reasons to believe the above, taking into account, among other things, that in the period January to September 2021 you have submitted to the IT system:
- 538 cases of claim for payment of remuneration for the performance of (specific activity). The total number of claims submitted for this activity by all contracted with the Organization (doctors of the specific specialty), amounts to 628. Therefore, you have registered 86% of the total number of activities with code (...) during the period under review.
- In 331 cases, a requirement to pay a fee for carrying out an activity with a code (...). The total number of claims submitted for this activity by all specialists with the Organization (doctors of the specialty) amounts to 1,204. Therefore, you have registered 27% of the total number of activities with code (...) during the period under review.
From 66% to 99% the requirements of
"The Agency, in the context of an ex officio investigation, has found that during the period July 2020 to August 2021 you have registered in the IT system a number of specific activities much greater than the total number of activities registered by all medical specialists contracted with the Agency during the period under review with the specialty (...)". Specifically, it was identified that:
- In 4,291 cases, a requirement for payment of a fee for the performance of the (...). The total number of claims submitted for this activity by all contracted with the Organization (doctors of the specialty), amounts to 4,348. Therefore, you have registered 99% of the total number of activities with code (...) during the period under review.
- In 4,288 cases, a requirement to pay a fee for carrying out the activity was registered with a code (...) and the description: (...). The total number of claims submitted for this activity by all contracted with the Organization (doctors of the specialty) amounts to 4,540. Therefore, you have registered 94% of the total number of activities with code (...) during the period under review.
- In 355 cases, a requirement for payment of a fee for carrying out the activity with a code (...). The total number of claims submitted for this activity by all contracted persons (doctors of the specialty) is 458. Therefore, you have registered 78% of the total number of activities with code (...) during the period under review.
- In 373 cases, a requirement for remuneration for a specific activity was submitted. The total number of claims from doctors of this specialty was 453. This means that this particular doctor had abused 82% of the total number of claims for this activity.
The same phenomenon occurs in two other cases where the doctor had submitted 79% and 66% of the requirements that all the other doctors of his specialty had registered in the GHS informatics system for these activities.
