Filenews 29 October 2024 - by Marilena Panayi
20% of operations (surgeries, visits to doctors, laboratory analyses, etc.) performed each year in the USA are, according to a study, considered unnecessary. The same percentage seems to be found, although there is still no in-depth study, in the health systems of European countries, while in Cyprus the Health Insurance Organisation is constantly alert and now, after millions of checks it has carried out and is carrying out on the registrations of health service providers, it has included in its design and implementation of a program that will concern, this time, the behaviour and abuses that take place on the part of its citizens/beneficiaries within the General Health System.
Abuses and fraudulent actions within health systems internationally were the topic of a recent conference held in Luxembourg by the country's National Health Fund and the European Association of Social Security Systems with the participation of more than 140 representatives from various European countries.
"It is easy to understand that in the largest countries the amounts at stake are many times higher than those that concern us here in Cyprus and at the Health Insurance Organisation," the director of the Organization Constantinos Panayides told F.
So, he added, "if we take into account our own data here in Cyprus, we can easily understand the magnitude of the problem of abuses, but also of deceiving or attempting to deceive health systems internationally."
"Let's take 2024 as an example," Panayides said. "This year, until the end of August, i.e. over a period of 8 months, the competent department of the HIO identified tens of thousands of registrations made by providers concerning claims for compensation as "suspicious". In total, between January 1 and August 31, 2024, 12 million claims for compensation had been submitted. Of these requests, after an audit, it was found that 65,000 had to be rejected, with a total value of €19 million. The reasons for rejecting these requests were either because the acts carried out were not medically justified sufficiently, or because providers exceeded the limits set by the HIO for specific acts/cases'.
At the same time, and on the basis of entries made in the GHS software, as well as in some fewer cases on the basis of complaints submitted by patients, the HIO in 2024 began investigating 132 suspicious cases (against specific providers). These cases concern the general behaviour of specific providers within the System.
For half of these cases the investigation has been completed and for the rest it is still ongoing. "Those completed resulted in fines amounting to €100,000" while in 2024 (to date), "cases of previous years were also completed which led to fines of €40,000".
"And these cases involved either abuses or an attempt to deceive the GHS. That is, providers enter into the software codes for compensation that refer to acts that they have never carried out or in other cases providers perform a specific act, but make a claim for another that results in greater compensation. There are also cases concerning the violation of regulations applied within the GHS by the Health Insurance Organisation in order to combat abuses. E.g. fixed number of referrals for examinations, etc. And of course, we had more serious cases where certain providers entered false information, such as wrong discharge dates, etc."
The competent department of the HIO, Panayides said, "is constantly alert and tries to identify all 'suspicious' cases. Of course and fortunately, the computer system is designed in such a way that allows it to detect on its own some behaviours that go beyond the limits of the "ordinary", which is very helpful."
Given the recent complaints from doctors of various specialties, "we are seriously considering the possibility of controlling the behaviour of beneficiaries within the GHS. That is, when we talk about abuses, we should not only think of health service providers but also of the recipients of these services. For example, very recently the neurological society had publicly denounced cases of beneficiaries who made unnecessary visits to doctors, thus creating both a misuse of resources and a problem in doctors' appointments. We are able to identify such cases and take action, although a direct penalty to a beneficiary cannot be imposed under our own law. When we say measures, we may, for example, look at the allowed number of visits or make changes to a co-payment, but what we are saying now is very theoretical because the relevant program has not yet been drawn up."
"But we have to say that other health systems of some countries can 'temporarily expel them', i.e. for a while beneficiaries who abuse or put a cap on the number of visits or other services they receive, etc."
Under no circumstances, Mr. Panayides clarified, "are we talking about seriously ill patients who justifiably use the GHS more often and for a greater number of services. We are talking, for example, as neurologists have said, about those who visit more than 3 or 4 doctors of a specialty, etc., for the same problem. Let us also say that whichever program is decided will probably involve spot checks, unless we have specific complaints to investigate."
Unnecessary operations 20%
During the conference held in Luxembourg, a study carried out in the USA showed that one in five operations carried out is unnecessary. For EU countries, no similar study has yet been carried out, however, "the experience of European health systems leads us to conclude that there is no significant variation in this percentage in Europe."
The conference, "was characterized as very important. This is evidenced by the fact that we also had with us health ministers of some countries, such as the health minister of Spain."
During the conference, in addition to the conclusions reached by some countries and beyond the measures taken by different countries to tackle abuses, the use of artificial intelligence by the various national health systems was extensively discussed.
