Filenews 10 July 2024 - by Marilena Panayi
In 12 days, a total of seven GHS health service providers were fined or their contract suspended by the Health Insurance Organisation, either because they were judged to have deceived the system by submitting claims for compensation for services they had never offered, or because they operated outside the rules and limits applied by the HIO.
Among the providers penalised were six doctors, specialists of various specialties and a pharmacist who, as the HIO found, supplied patients with larger quantities of medicines than doctors had prescribed.
Of particular interest is the case of an anaesthesiologist, who was fined €500 because, as it was found, he recorded visits and acts in the files of beneficiaries in their absence, something that is prohibited under HIO instructions and caused the reaction of patients who proceeded with the relevant complaint.
According to the HIO announcement, the anaesthesiologist was fined "following complaints from beneficiaries and based on the information before the Organization it was found that he proceeded to submit outpatient claims for visits that did not take place and/or were created at a time when the patient was not in his practice. In particular, following an investigation, it was found that the anaesthetist submitted outpatient requirements: (a) for visits that did not take place, creating a visit in the absence of the beneficiary and gaining access to the medical record kept by the Agency in the computer system for that beneficiary and (b) for a visit created on a date later than the actual date of the beneficiary's visit. As the HIO points out, "relevant is the announcement of the Organization dated December 11, 2019 entitled "Advisory activities/Clinical notes", according to which the creation of the visit in the IT system must take place at the time of the patient's visit.
Another case concerns an orthopaedic doctor who was fined €1000. "Following complaints from beneficiaries and on the basis of the information before the Agency, it was found that the orthopaedic specialist under examination proceeded to submit outpatient claims for activities whose conduct and/or necessity of their use is not justified and/or substantiated, including referrals and/or prescriptions issued, since the completion of the field of clinical notes at the respective visits was incomplete». In this particular case, the HIO recalls "an announcement of the Organization dated 11 December 2019 entitled "Advisory activities/Clinical notes", according to which it is mandatory for doctors to fill in the field of clinical notes, which must describe the findings/findings from the examination of the beneficiary as well as substantiate the reasons why they have carried out these activities. In addition, the Announcement dated November 7, 2020 states that clinical notes must be clear and sufficient to justify any further actions, such as referrals, prescriptions and any activities. Also, clinical notes should be complete, comprehensive and facilitate effective and two-way communication between providers. Furthermore, each referral shall contain the necessary medical information, its justification based on medical indications, and diagnostic thinking."
A fine of €500 was imposed on a rheumatologist who "based on the information before the Organization it was found that he proceeded to submit outpatient claims for activity compensation with a quantity greater than that allowed according to the Specialty Activity Rules. In particular, following an investigation, it was found that an activity was required with a quantity exceeding the quantity that may be required'.
A fine of €300 was imposed on an orthopaedist who "based on the information before the Organization it was found that he proceeded to issue referrals for physiotherapy in excess of the 30% restriction on total monthly visits set by the Organization with the announcement dated June 13, 2023. Specifically, following a relevant investigation, it was found that referrals to physiotherapists were issued by the Orthopaedist in more than 30% of the total monthly visits, while he had already received a letter of formal notice."
Regarding the pharmacist, who was fined €300, as the HIO states in its announcement, "it was found that he proceeded to submit claims for compensation for the supply of a quantity of pharmaceutical products for monthly use that exceeded the medical needs of the beneficiary. Specifically, after a relevant investigation, it was found that: (a) a larger quantity of a medicinal product was executed by the Pharmacist than corresponds to the daily dosage prescribed by the doctor in each prescription, and (b) the Pharmacist carried out a monthly execution of more than one prescription and/or repetition of prescriptions, which was not permissible and reasonably expected to be administered".
It is recalled that on June 28, the HIO had announced that it had suspended the contracts of a dermatologist and a dentist because it was found that they had submitted claims for compensation for services they had not offered. An investigation into the two doctors is ongoing.
