The proliferation of fraudsters into the health sector is a cause for concern. All of us, at one time, must visit that dreaded place: the hospital. It is so puzzling that our forefathers lived up to their 90th anniversary and beyond without doing regular medical checks or getting timely treatments. How did they do it? Is it that the doctors of the past were genuine professionals? Why are people of today, financially independent with great medical insurance and attendant quality health care services having serious medical conditions?
Those were some of the questions in Alice’s (another name withheld) mind as she sat by her brother’s sickbed wondering what had befallen him. Nigel NM (full name withheld) is a 42 aged professional accountant whose woes started six years ago once he opted for health insurance cover. His new senior role entitled him to free medical insurance.
One of the available benefits under the cover was regular medical check. To make use of the benefits, Nigel visited one of the listed health facilities for routine medical checkup. He opted for a complete checkup which revealed several health conditions: high blood pressure, three bad teeth which needed filling, high sugar levels, and low count of some cells in addition to a condition on his liver. They said it had something foreign on it.
If you have ever been in a hospital, you know what it means. You get an urgent urge to have any diagnosed conditions treated. Every patient is vulnerable to their doctor. Many times, we don’t think about second opinion, especially if the medical bill is none of our business.
And that is how Nigel was recommended for a surgery. It was done by Jeremy. He advised Nigel of a choice of some top public and private hospitals. “If you prefer hospital xx, my professional fee will be 1.2m or we do it at hospital yyz and my professional fee will be xx, and they will charge you about 2m for the use of their facilities.” After the operation, Nigel has not been lucky as the first operation gave rise to the next, and now is slated for the third! He still wonders why he gave in to the surgery without having first sought second professional opinion.
A review of most advanced treatment procedures in the several hospitals indicates majority of people going for surgery are on health insurance.
Nigel’s case is not alone.
At one of the hospitals, a kid who had died was convinced to keep it [lifeless body] on the hospital bed for two more weeks so as to claim more insurance payout. The medical practioner got to know that the victim was on life insurance, and colluded with the father of the kid to delay declaring the date of death so as to keep having the kid on some expensive drugs during the extra period on the hospital bed. Although the cause of death was revealed as pneumonia, one of the parents still thinks it was due to drug overdose. They kept administering different expensive drugs albeit with little improvement.
The story of NMA (name withheld) is the scariest.
He woke up one morning not feeling well and decided to pass by the hospital for medical checkup. He was checked up and found generally fine. The ‘doctor’ diagnosed fatigue and recommended a bed rest and some painkillers.
When he went to the in-house drug shop at Jeremy’s clinic for pain killers and some ‘relaxing drugs’, the pharmacist asked whether he needed drugs made in India or Europe, adding “you don’t have to mind the price, as your insurance cover suffices.” The wife asked “what is the difference?” Aren’t they all approved for sell by the National Drug Authority, to which she murmured “differences in price and customer preferences. One is for a high-end market.”
Two weeks later, he came back feeling general body itching, which culminated into fever, and general weakness. He could no longer walk on his own. He was admitted. Hours later, he started feeling pain in the legs. It worsened. The Nurses tried their best in vain. Suddenly ‘he felt like all muscles in the legs have been cut off from the general body, he could not move the legs nor feel anything’. They called in physiotherapist and could not be of help. The condition was getting out of hand. John’s whole body below the umbilical cord became numb. He could not feel anything or sensation. Reality finally struck: he had been paralyzed. He was subjected to a full medical examination which revealed nothing.
Seeing the condition was getting out of hand, Doctors referred him to a government hospital, describing the illness ‘strange,’ as seen on the referral letter. Of course, the same doctors at the clinic were to treat him at hospital. They just did not want to handle such confusing condition at their clinic. That is the new dilemma we are in: a doctor will make an appointment to see you at his clinic and then refer you to another hospital so that you pay double consultation fees. It is a real conflict of interest where a doctor is employed in more than two hospitals or clinics.
NMA’s condition was indeed strange. By the time he arrived at the hospital, he was oozing blood, probably due to fatigue and wariness of the cause of the condition. At the referral hospital, some of his close family members came to see him. “I moved closer to greet him and in a very soft tone, he said he wasn’t fine. Looking pale, scared, rejected and puzzled he said: “Man, I can see I am going to die, even my leg is broken.” At this time, people were moving away from him in the general admission area he had been put. Even some nurses were scared as they had not yet diagnosed the illness. They thought, rather wrongly, that it was Ebola case.
Being disabled in the legs, and oozing blood was scarily indeed. The wife was standing there almost exhausted with shock. Clothes shocked in the son’s blood. It was a typical scene from the war of the worlds. People running away. When the doctor arrived, he was declared NMA a ‘high risk’ patient and ordered that he is quarantined i.e. put in a special ward pending diagnosis of the disease. This had its own implications, cash wise.
The events unfolding were scarily. Even the wife began minding about their own health. “‘I’ve been in contact with the patient. If it is Ebola, I am gone’. Somehow, I tried to think other things, albeit unsuccessfully. I felt very dirty and needed to bath and change clothes right away. Human beings can think and do anything to get hope”, she said.
Immediately, the Nurses took the required samples – blood, urine, saliva, etc… Thereafter, he was properly washed, cleaned and examined. His fears were expelled. He had not broken any bone. He neither carried HIV nor Ebola nor Syphilis nor any other known death passport illness. It was just a strange illness and needed further body examination.
The financial bit was getting tight. His special accommodation room went for Ugx. 400,000 per night, notwithstanding the lab tests, meals, medicine. The following day, the Doctor called me in his office.
Here is the Doc.
“Is John your husband? His symptoms are usually associated with HIV/ AIDS, TB, Syphilis or rabies. These diseases produce viruses that move in the blood, affecting the red cells. They may also affect the spine, thereby causing the condition your husband is in. However, your husband has none of these diseases. So, we have to put him in a CT Scan. It costs Ugx. 550,000.”
Ten minutes later, the Doc came back with a different story. “We have tried to scan the Spine, but the CT scan image is not clear. He needs an MRI scan. It will show us a clear image of the spine. An MRI scan costs Ugx. 650,000 and it is payment before scanning.” I was starting to get feverish due to the bills. Anyway, I rushed to the ATM, and returned with the money.
The following day, the Doctor called me into his office: NMA is suffering from a rare disease called Transverse myelitis (TM). It is a disease of the spine, caused by inflammation of the spinal code due to HIV or syphilis. Since John has no HIV or syphilis, then it is likely that something hit him in the back, causing a swell to the spine, which controls the brain and other vital parts of the body. So, the legs are accordingly paralysed. Out of 100 patients who have suffered from the same disease, 85% have fully recovered, and 15% have not died but have remained lame for life. And for the bleeding, there is a polyp extrusion, this will need a simple surgery, and you can take the patient immediately after. It is cheap. It costs only Ugx. 1,230,000.”
Well, this meant more money and more waiting. Even then, the Docs explanations of the disease were not quite clear, only that Google had given me a better explanation of the same disease when I searched on the net.
The surprising part of it was that the treatment for TM is physiotherapy, nothing else!
Jeremy’s clinic was thriving on the back of a fraudulent business model: admit patients, collect consultant fees, diagnose and treat the patients, and if things fail, refer them. On the surface, this was a normal business model.
We discovered instances of inflating drugs sold in their hospital clinic, consultant fee payments to trainee doctors and nurses and unnecessary treatment, some of which became fatal.
It is a human condition to want to live a healthy life. When a doctor informs any patient of a certain diagnosed illness, the tendency is to want medication as soon as possible before things get out of hand. For this reason, few patients if any seek a second Doctor’s opinion over their diagnosed health condition. Considering the personal nature of health issues, people tend to get used to a specific doctor. They find it ‘over exposing’ themselves to have to meet another doctor to explain their health conditions.
Investigating health related complaints is very complicated. Some patients are too afraid to incriminate their Doctor. S/he has seen them in and out and kept their tricky health condition a ‘secret.’ They feel obliged to protect them as well.
As you are aware, documentation alone rarely solves cases. You need corroborating evidence. We had to interview some patients, if we were going to be believed. We wanted to find out whether Jeremy subjected people to unnecessary tests or administered different drugs to people on health insurance than those without.
After obtaining all the necessary legal approvals and working with an investigative police officer, we obtained contacts from patience files – specifying clearly those on insurance cover and those without any insurance cover.
One of the good investigation practices is to (i) take suspect and witness statements, (ii) collect documents and review them, (iii) identify a fraud theory and validate it, and (iv) interview the suspects so as to connect the dots. At this stage we had accomplished steps (i) and (ii).
Today, NMA lives in a wheel chair. And his career came to a standstill.
He still thinks the drugs he took when he first visited the clinic could have been the cause of his suffering. When it comes to your health, try to get a second professional opinion.
Copyright Mustapha B Mugisa, CFE. All rights reserved. 2013. Article first appeared in SBR, www.sbreview.net. Nov 2013, issue.