KUALA LUMPUR, August 2 — ProtectHealth Corporation has uncovered abuse of the Madani Medical Scheme (SPM) by private health care providers, after the scheme was downscaled last February due to funding constraints.
In a written Dewan Negara reply last Wednesday, Health Minister Dzulkefly Ahmad said ProtectHealth’s review of claims from more than 100 private general practitioners (GPs) was prompted by a surge in claims from 20,000 to 25,000 per day in early December 2023 to 40,000 to 50,000 per day in the final five days of December (December 27 to 31, 2023).
The review identified multiple “violations of SPM service terms and conditions”: using up SPM beneficiaries’ allocations despite their not being sick; unregistered GPs “colluding” with SPM panel GPs to make claims under the scheme; false claims (no medicines or services, like tests or treatments, were provided); and the sale of medications at the counter without doctor consultations.
“Actions taken so far include terminating two GPs from SPM and suspending 44 GPs, who are currently under investigation,” Dzulkefly told Senator Aziz Ariffin.
Dzulkefly did not provide data or the amount of funding involved in the fraud uncovered in SPM so far, but said ProtectHealth prevents abuse of the scheme through continuous monitoring via its claims management, medical audit, and medical analytics departments.
This includes one-time password (OTP) verification, patient confirmation through phone calls, field audits, patient meetings, social media monitoring, and data analysis using PRIMIS (Primary Care Information System), which manages payment and claim processes.
ProtectHealth, a fully-owned subsidiary of the Ministry of Health (MOH) that functions as the third-party administrator of SPM, has partnered with over 2,400 GP clinics to provide fully subsidised acute outpatient treatment for minor illnesses to low-income beneficiaries. As of June 30, 2024, a total of 2,518,630 patients have been treated under SPM.
Dzulkefly did not state if ProtectHealth has audited all 2,400 panel GPs of SPM, following the suspension or termination of nearly half of the 100 GPs in the initial review.
Since last February, the nationwide coverage of SPM was reduced to the 10 districts from the pilot phase of the programme in June 2023: Kuala Lumpur; Gombak, Hulu Langat, Petaling, and Klang in Selangor; Johor Bahru (Johor); Kinta (Perak); North East (Penang); Kota Kinabalu (Sabah); and Kuching (Sarawak).
Dzulkefly told the Dewan Rakyat last February 29 that SPM was expected to run out of money in April, based on an estimated cost of RM1.7 million a week in 10 districts. Out of the RM100 million allocated for SPM from the federal government in Budget 2024, the minister said RM78.73 million was already spent as of February 29, with just RM21.3 million left for the rest of the year.
