Filenews 6 August 2024 - by Marilena Panayi
It rains penalties on the GHS and at the moment the service providers of the System of almost all categories and specialties are under the microscope of the HIO.
Among them are hospitals, one of which seems to have been employed by the Health Insurance Organization for several months, but no final decisions have been taken so far.
In the last month, three hospitals, seven doctors, a dentist and a pharmacist have been fined or suspended or warned to suspend contracts. At the same time, the HIO has already intensified mass audits per service and per specialty/category of providers, with some of these cases being at an advanced stage of investigation.
The most frequent reason why the HIO imposes penalties/fines concerns the violation of GHS regulations in force or the repeated incorrect entries (codes or acts) in the System's software.
The most frequent reason why contracts are suspended and/or terminated or reports are made to the Police, concerns the registration of false information in the software or the registration of claims for services that were never offered to GHS beneficiaries.
Of particular interest, as expected, was the case of a hospital which, as "F" published last week, received a stern warning for the termination of its contract by the HIO, which gave the hospital one month to comply with the regulations and correct the errors, while two specific doctors were called to explain the altered data they entered in the GHS software in order to increase their compensation from the Agency.
For this hospital, the HIO reached this decision, since in case of a contract suspension, there would be huge inconvenience for both the rest of the doctors of the hospital and their dozens of patients who have scheduled surgical and other operations in the next few weeks.
The two doctors and the hospital, as found both by checks on the GHS software and by checks on patient records kept by the hospital, entered, for example, incorrect dates of admission/discharge in order to increase their compensation, while in some cases resulting in the data in the software not being consistent with the data in the patient files.
If this hospital does not comply after 30 days, it will be at risk of being discharged from the GHS. In any case, whether there is compliance or not, it must be assumed that a large fine will be imposed.
"The number of cases investigated by the HIO has not increased much compared to previous years," the head of the relevant department, Konstantinos Panayides, told F.
"But now the HIO is also better organized, there is enough data recorded and certainly the decision to make public the cases that result either in a fine, or in suspension or termination of contracts or other penalties has helped to make known the controls exercised daily by the Organization."
He was seeking compensation for visits that never took place
The administrative fines imposed last month by the HIO range from €300 to €5,000 and in most cases related to violation or non-compliance with regulations applicable within the GHS.
Regarding the two hospitals that were fined, according to the relevant announcements of the HIO, in one case, the hospital registered as in-hospital, services that are reimbursed in the context of outpatient care and in the second case, the hospital registered claims for compensation using incorrect codes. The first hospital was fined €5,000 and the second €1,000.
Particularly striking is the case of a doctor, an anaesthesiologist, who, according to the HIO announcement, registered claims for compensation for services he had not provided.
"Following complaints from beneficiaries and based on the information before the Agency, it was found that the anaesthetist under examination proceeded to submit outpatient requests for visits that were not made and/or created at a time when the patient was not in his practice.
Specifically, following a relevant investigation, it was found that the anaesthesiologist 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 IT system for that beneficiary and (b) for a visit created in the computer system, on a date later than the actual date of the beneficiary's visit'. The anaesthetist was fined €500.
According to the announcements posted on the GHS website, a fine was imposed on 6 doctors (two orthopedists, two rheumatologists, an anaesthesiologist and a urologist).
As for the suspensions of contracts, these concerned a doctor, dermatologist and a dentist.
The dermatologist, according to the relevant announcement, allegedly "had submitted claims for compensation and has therefore been compensated for activities that may not have been provided during the visit of beneficiaries and/or visits of beneficiaries that may never have taken place. The Agency has appointed an investigating officer, who will carry out an appropriate investigation and prepare a relevant conclusion on the basis of which the Agency will decide to terminate the contract with the provider in question or to lift the above suspension and reinstate the provider to the GHS".
As far as the dentist is concerned, the relevant announcement states that "he had submitted claims for compensation and has therefore been compensated for carrying out activities that may not have been carried out by the dentist in question, but by another".
New practice by HIO
The checks meticulously carried out on the registrations of health service providers in the GHS software, as is well known, have been reinforced by on-the-spot checks, mainly with regard to hospitals and, as Mr. Panayides said, "now a new practice has begun to be implemented".
In simple words, he explained, "the HIO monitors and processes the behaviour of providers of a specific category/specialty for a specific service/operation, and monitors the entries in the software by all professionals/providers of this group."
From this type of audit, he added, "we already have some results and in some cases penalties may be imposed."
Regarding the providers that have been fined or their contracts suspended by decisions made public from June 28 to August 2, Mr. Panayides said that "following a relevant decision, publication was made on a case-by-case basis. Now, it has been decided and a detailed bulletin will be issued once a month for all cases together."
