An inspection conducted in to unfounded expenses in health insurance in 2019 has led the Health Board (Haigekassa) to reclaim close to €420,000 from health care institutions in Estonia.
The Health Board pays for medical bills that healthcare providers submit, after someone has gone to see the doctor and received treatment. The Board also has a right and duty to check the validity of treatments patients have received. Thereby a monitoring is done to discover any possible violations or errors in funding healthcare.
"Verifying health insurance spending is one of the most important tasks for the Health Board. For that, the Board does constant supervision, using different methods and mechanisms within limits of authority and obligation," said Maivi Parv, board member of Health Board.
Medical bills, sick-leave, and prescriptions go through an automatic control, which allows prevention and identification of simple errors, which for example can be faulty bills, incorrect service codes, incorrect amount for prescriptions, etc.
Health Board also investigates medical bill database queries and data to assess the accuracy and validity of medical bills. The Board also investigates the justification of presented paid medical bills. Standard queries have shown that the largest part of reclaimed money has come from bills that have been presented twice by healthcare providers. In 2019, Health Board investigated close to 16,000 medical bills, of which 3,500 were not justified adequately. Those bills made up €250,000 of reclaimed funding.
To further support the quality of healthcare services, Health Board will also do targeted checks, where the presented actions on medical bills are compared to the actual treatments the patient has received. Medical justification is also assessed during this process.
"Targeted selections are an efficient method for the Health Board to help us discover any possible violations and errors. Selections are made due to high costs of treatment or if people are not satisfied with the healthcare they have received. Investigations are also made into critical sectors of healthcare, for example this year we will investigate funding in relation to treatments regarding COVID-19, including paid sick leave and remote digital receptions," Parv explained.
Last year, Health Board checked 3,200 medical documents, which included medical bills, temporary incapacity for work certificates, prescriptions, medical histories, and health cards. Errors were discoverd in 25 percent of the checked documents and €164,300 was reclaimed from healthcare providers.
Health Board also does regular investigation in to contractual partners' work. Parv said that agreed upon conditions of those contracts are checked by trusted doctors to see if there have been any violations in presented bills and if healthcare has been adequately accessible. In addition, trust doctors also check the services provided by the provider on it's websites and will compare those to actual procedures. On the basis of a patient complaint, trust doctors will also do spot checks to contractual healthcare providers.
"During checks, trust doctors will investigate how work is organized and if services are accessible. Also if the provider is available at the promised times and a list of costs of services is easily found. Availablity of pre-registration, queuing process are also checked, along with if the services provided are correctly inserted to the Patient Portal (Tervise Infosüsteem)," Parv added.
In addition to regular data analysis, the Health Board has also started using machine learning to discover any errors. "Machine learning allows us to create models using prior investigations to predict which bills are incorrect in form or content. This helps us discover, which providers or services to turn further attention to. Machine learning is an important tool in making our investigation more efficient," Parv said.
Many important violations have been discovered by way of patient complaints and feedback. The Board gets up to 200 yearly complaints on average and these help discover violations from first-hand experiences. Violations and inadequate healthcare is difficult to discover without the help of patient complaints, the board member added.
The ability to check medical bills at digilugu.ee has given way for even more complaints. Parv calls patients to always check their medical bills and to contact Health Board in case of any suspicions.
"We have received info from people that they have actually not been to that establishment at the time of their bill, or they have not received the service on the bill. Patients have also stated that they have paid their bill on the location and it has not been entered to the database, which is illegal behavior by the provider," Parv explained.
She added that in case of a possible violation, made complaints have given a signal to the Health Board for further action.
The Board plans to include patients more in their investigations going forward. "One of the ways is for us to notify people by e-mail, if their bills have been forwarded to the Health Board. In addition, we are adding an option, which people can use to dispute their bills digitally. Clicking a button will notify the Board and with the provided information, we will turn to the provider for justifications and explanations," Parv said.
That option will be available to patients starting in 2021.
Trust, but verify - a principle that is also in use for the Health Board. "We trust our partners and know that quality healthcare is our commong goal. We also presume that providers are not abusing common funding. But trust alone is not enough and therefore constant supervision is necessary," Parv added.
Violations and errors are taken seriously by the Health Board. "If we identify a violation, we will issue a reclaim and in the case of repeated infringements, fines will be issued. Last year we reclaimed €411,000 from 500 providers.
For many reclamations, it ends up being a unintentional mistake, because there are a lot of bills to go over. Providers issue the same bill twice, make coding mistakes on bills, add the wrong service to the bill. Parv said that many partners will notify the Health Board themselves, when they discover an incorrect bill or entry.
"We do see systemic fraud at times, for which the Health Board increased fines for since last year. Depending on severity of violation, a fine of up to €500,000 can be issued. The contracts of partners will also be looked into in case of intentional violations," Parv said.
Although, the Health Board does hold the right and duty to check healthcare providers and services, the methods with which they can do so are limited and include a lot of manual labor. For example, it can not yet be systematically controlled, which specific services have been provided and were they in sufficient amount. The Board also does not see, whether or not the person has come for their visit.
"We can only rely on medical bills and documents, but we will never be able to check each reception," Parv acknowledged.
Cooperation with the Police and prosecutors is also critical. For large-scale violations and suspicions, the Health Board will forward information to the police, who will start criminal proceedings, if needed.
Parv concluded that still, the best way to investigate use of funding is by supervision, where machine learning and automation is expanded upon.
Editor: Kristjan Kallaste