KUALA LUMPUR, August 5 — ProtectHealth Corporation has identified about RM1.5 million in disputed claims from Madani Medical Scheme (SPM) panel general practitioners (GPs) that have been withheld or recovered from payment.
Health Minister Dzulkefly Ahmad also said more than 200 private GPs have been audited or investigated to date by ProtectHealth, a fully-owned subsidiary of the Ministry of Health (MOH) that acts as a third-party administrator (TPA) for the scheme.
“Approximately RM1.5 million in disputed claims has been identified and is being withheld or recovered from payment,” Dzulkefly told CodeBlue in a statement yesterday.
“While some claims may involve violations of SPM terms and conditions, it is important to clarify that not all of these cases constitute fraud.”
Last Friday, CodeBlue reported fraud committed by SPM panel GPs in a ProtectHealth review of the scheme, following a 100 per cent surge in claims within one month last December, according to the health minister’s July 31 written Dewan Negara reply.
ProtectHealth’s review showed multiple violations of SPM terms and conditions, including GPs using up beneficiaries’ allocations despite their not being sick, unregistered GPs colluding with SPM panel GPs to make claims, false claims for drugs or services not provided, as well as selling medications without doctor consults. Two GPs have been terminated from SPM, while another 44 were suspended.
“Further actions being considered include legal proceedings and filing reports with the Malaysian Medical Council (MMC) for possible disciplinary action. ProtectHealth is in the midst of finalising the compilation of documentation and evidence,” Dzulkefly told CodeBlue yesterday.
When asked if the MOH was following up with the safety of patients who were given medications without doctor consults, the health minister simply said: “ProtectHealth is committed to continuously monitoring GP providers to ensure that medications are only prescribed following proper consultations.”
Dzulkefly also explained that all claims from SPM undergo stringent verification before payment is made, including verification and approval of claims by checking on the reasonableness of consultation, diagnosis, prescription of drugs, and other procedures and investigations done. Claims with discrepancies are rejected.
With phone verification, patients are contacted to check on, among others, patient attendance, treatment (consultation, procedure or any investigation) given by the doctor and type and quantity of drugs prescribed.
ProtectHealth also conducts continuous audits of SPM through regular random audits by the Claim Management Unit and Medical Audit Unit, as well as targeted audits based on risk profiles. Risk profiles on panel clinics have been developed based on findings from claim reviews, phone verifications, and audits.
Finally, ProtectHealth conducts surveillance, where the TPA reviews documents at the premises of an SPM panel clinic. This includes checking a clinic’s internal records and documentation on claims, as well as interviewing doctors and staff.
Dzulkefly denied that the downscaling of SPM geographical coverage was due to GP fraud, after the scheme was limited last February to 10 districts from previous nationwide coverage.
“The decision to refocus implementation areas was driven by the overwhelming popularity and financial sustainability considerations of the SPM programme and not due to fraud concerns.”
The health minister added that RM9.6 million in allocation remained for the Madani Medical Scheme as of July 30, less than 10 per cent of the RM100 million allocated under Budget 2024.
“ProtectHealth is demonstrating its commitment to ensuring the highest standards under Skim Perubatan Madani. As highlighted in the report, the stringent audit processes and claim verifications underscore our dedication to delivering quality services, ensuring the authenticity of claims, and safeguarding government allocations for this critical programme,” Dzulkefly said.
“The actions taken reflect MOH’s unwavering focus on accountability and the responsible use of public funds.”
MMA: ProtectHealth Not Under MOH’s Registry of TPAs
The Malaysian Medical Association (MMA) questioned the lack of scrutiny of the functioning of ProtectHealth as a TPA or a managed care organisation, especially since the company isn’t listed on MOH’s registry of TPAs.
“Transparency and accountability in all aspects of health care administration are crucial for maintaining public trust and ensuring optimal use of resources,” MMA president Dr Azizan Abdul Aziz said in a statement last Saturday.
According to ProtectHealth’s website, Health director-general Dr Muhammad Radzi Abu Hassan is chairman of the company’s board of directors. Another position on the board, currently vacant, is allocated for the MOH secretary-general. A representative from the Ministry of Finance (MOF) is also on the board.
MMA expressed support for action to be taken against doctors found to be involved in unethical practices, following “upsetting revelations” of fraud uncovered in the Madani Medical Scheme.
“However, the MMA firmly believes that the actions of a few should not tarnish the reputation of the majority of the dedicated general practitioners (GPs) who serve their communities with integrity,” Dr Azizan said.
“The vast majority of GPs in Malaysia are committed to providing high-quality care and upholding the highest ethical standards. We stand in strong support of these professionals who form the backbone of our primary health care system.
“While we do not condone any form of misconduct, it is crucial to recognize that these instances are isolated and are not representative of the broader medical community. The MMA continues to advocate for stringent ethical practices and supports measures to ensure accountability within the health care system.”
Like MMA, two other doctor groups – Federation of Private Medical Practitioners’ Associations Malaysia (FPMPAM) and Medical Practitioners Coalition Association of Malaysia (MPCAM) – have similarly hit out at ProtectHealth, demanding an audit of the TPA and not just panel GPs.
FPMPAM said ProtectHealth’s review suggested that the TPA did not put adequate processes in place to prevent “moral hazards”, while MPCAM urged the National Audit Department to audit ProtectHealth’s mechanisms and financial management.
ProtectHealth has partnered with over 2,400 GP clinics to provide fully subsidised acute outpatient treatment for minor illnesses under SPM to low-income beneficiaries. As of last June 30, about 2.5 million patients have been treated in the programme.
