Optometrists’ experience of healthcare fraud, waste and abuse (FWA) and strategies to combat it

Abstract

Background: South African private healthcare is funded through medical aids and out-of-pocket payments. Annually, R22 billion is lost to medical fraud, waste and abuse (FWA) threatening the sustainability of healthcare delivery. Healthcare providers are often accused of unethical practices and various forms of FWA.

Aim: To assess the optometrists’ experience of FWA and the strategies to combat FWA.

Methods: A quantitative study was conducted amongst optometrists using a structured questionnaire and data was analysed using descriptive statistics.

Results: Most (75%) respondents were aware of FWA. About 41% of respondents were audited for FWA, of whom two-thirds were Black males. The Preferred provider Negotiators conducted 27% audits, followed by Discovery (16.5%), Government Employees Medical Scheme (7.8%) and Medscheme (5%). Iso Leso and Opticlear networks conducted 3.9% each. About 7.8% were found guilty of FWA, of whom 87.5% were Black practitioners and 12.5% Indian practitioners. Claiming for spectacles but dispensing sunglasses (5.9%) and over-servicing (4%) were highest ranked offences. Common sanctions were claw-back (75%) and indirect payment (37.5%). Practitioners implement identity checks (94%–96%), coding training (89%) and accurate record keeping (93%) as anti-FWA strategies. Excessive codes and lack of standardised tariffs were challenges to fighting FWA.

Conclusion: Optometrists use identity checks, coding and billing training as anti-FWA strategies. Coding and billing complexities are the main sources of FWA cases. Black and Indian practitioners were more likely to be identified for FWA and found guilty than White practitioners.

Contribution: The study highlights the forms of FWA and suggest integration of controls to effectively curb FWA.