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Wed 25 Mar 2015 01:25 PM

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Dubai ramps up drive to beat medical fraud

Healthcare regulator launches data analytics project to help eradicate fraud, inefficiencies

Dubai ramps up drive to beat medical fraud

Dubai’s healthcare regulator has launched a data analytics project to help eradicate medical fraud and other inefficiencies.

It is the latest in a series of government efforts to improve Dubai’s healthcare industry – the most significant of which was the introduction of mandatory health insurance last year.

Dubai wants to create “the best healthcare system in the world”, according to regulator the Dubai Health Authority (DHA), and compulsory health cover for the entire population is expected to cut the number of false claims made each year by unscrupulous providers.

The DHA announced on Wednesday that it has teamed up with software provider SAS to adopt an advanced analytics system that will be used by the regulator to track claims, monitor patient diagnoses, prescriptions and clinical outcomes, and assess overall financial performance.

Meanwhile, health insurers will be offered a subscription to the software to give them more information about treatments and help them to be more cost-effective. SAS refused to disclose the exact subscription price but said it was equivalent to less than 1 percent of premiums paid in the market.

Speaking to Arabian Business, Dr Haidar Al Yousuf, director of health funding at the DHA, said the new data project would “drive market efficiency and identify wasteful practices, including instances of fraud or abuse”.

“The software does this by monitoring utilisation trends,” he said. “Let’s use the example of a headache. In most cases, headaches do not require an expensive CT scan or MRI. The new system is smart enough to make links between a diagnosis and the action taken to manage and treat a particular condition. In short, it will flag up unnecessary use of CT scans by identifying health providers that routinely send a large proportion of their headache patients to have a CT scan.

“Maybe that neurologist is extremely specialised, sees complex cases and therefore requires more CT scans than average, and that’s fine. But there could be a pattern of abuse where the provider has decided to do more of them to make more money out of it.

“We will be able to pinpoint this behaviour immediately and act on it before someone – be it the government, insurer or the public – becomes out of pocket as a result.”

In an interview with Arabian Business in September 2013, Michael Bitzer, the chief executive of Dubai’s largest health insurer, Daman, estimated that around 200,000 false claims are processed in the emirate each year – representing billions of dollars – but admitted it was hard to pinpoint cases of outright fraud and others of simple abuse to make extra cash.

Al Yousef said the new software will make it easier to distinguish between the two, and enable the Dubai government to gather, for the first time, hard data measuring the extent of health fraud in the emirate.

“At this stage all we have to go on is US statistics, which estimate that [the amount of money lost globally] to health fraud is about 3 percent of the total global spend on healthcare. This means in Dubai it would equate to about 3 percent of our annual AED10 billion budget. Once the system is up and running we will be able to clarify and update this estimate and there is undoubtedly more work to do.”

Mandatory health insurance should help to drive down instances of abuse, Al Yousef added.  “What it will do is provide guaranteed funding for providers. So where previously the insured population was small, some providers that had additional capacity may have had to use not very straight methods to ensure their services were taken up.

“But as the population gets covered and as the insurers basically start to get more clients then there is less need for them to abuse the system because there is more demand for the supply. At some point, as the insured population gets even larger, demand will start exceeding supply, creating new investment opportunities in Dubai healthcare.”

However, he predicted the new rules would lead to a degree of consolidation activity among insurers, as they become under increasing pressure to improve the quality of service provision. “Insurers will need economies of scale to keep profit margins low,” he said.

The first phase of the mandatory insurance rules came into force in February 2014, requiring companies with 1,000 or more employees to provide their workers with health insurance by October.

In phase two, companies with 100 to 999 employees will have until the end of July 2015 to comply. Companies with fewer than 100 workers have until the end of June 2016 to provide coverage.

Al Yousef also noted that widespread instances of multiple people on low incomes using one insurance card to seek medical treatment would “reduce by default”, because, by 2016, health insurance cards will be abolished entirely and Dubai’s population will use only their Emirates ID cards when they visit a doctor. The ID card will hold details about their insurer and the level of cover provided – “we want to make sure your wallet doesn’t get any heavier,” said Al Yousef.

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