USZV employee got preferential treatment while management refuses to fully cooperate with Inspectors.
PHILIPSBURG:— Recently local media picked up on two medical referral cases whereby it was stated that procedures were non-existent or violated and that preferential treatment was given to a USZV employee.
As the Inspectorate had already plans in place to audit the referral department of USZV it decided, in anticipation of this audit, to investigate these two cases. One concerns a USZV employee that was sent abroad for a control and the other one a ZV insured (one of the insurance funds falling under USZV) patient that had to be flown out urgently. USZV spends approximately Naf. 30M per year on medical referrals. It is of utmost importance that all patients that are referred abroad for medical consultation or treatment receive necessary care that is of sufficient quality and safe and that the funds are spent wisely.
The Inspectorate has finalized it report on the case of the USZV employee and expects to finish the other case on a short term. Based on the investigation of the case regarding the referral of the USZV employee the Inspectorate has concluded the following:
• There is no evidence of the existence of any approved regulation, written policy or procedure for the medical referral of USZV employees.
The Inspectorate is deeply concerned about the absence of a written and approved regulation and procedure for medical treatment (and referrals) for USZV employees and their family members. As a result of this, the USZV employees and their family members are – first and foremost – confronted with undesired legal uncertainty about their rights to quality medical care (access to medical care).
In addition, the lack of these written procedures and policies promotes fraud. It creates the possibility that requests for medical treatment and care are arbitrarily approved or denied (one employee may receive permission for a consultation abroad while the other may not), and – as a result of this – that the available financial means are abused.
• In the case of the USZV employee, no documentation was made available that justifies the necessity of the medical referral itself, the need for the USZV employee to receive the approved medical treatments and of the length of stay abroad
The Inspectorate is very concerned about these findings as the concerned USZV employee might have been sent to Curaçao unnecessarily and remained there at the expense of USZV for a much longer period (3-4 times as long) than required. The Inspectorate is aware of the fact that the funds used by USZV are not directly regulated by a National Ordinance, but it finds that this does not justify financial waste by a public entity, especially not if the entity is established by law and uses public funds to cover its operational expenses.
• In the case of the medical referral of the USZV employee, no report was received from the specialist abroad nor was the Inspectorate informed that such a report was due.
Under normal circumstances, where a patient is referred abroad by a local medical specialist via USZV’s medical referral department, it is expected of the specialist abroad to report back to USZV about the diagnostic or therapeutic results. This report can also be used by USZV to verify that a patient indeed went to his/her consultations and that the requirements for referral (e.g. health benefits) were met, and to inform the local specialist about further treatment instructions. In this case, no report was received nor expected and – as a consequence – the abovementioned evaluation of both the need for the referral and the acquired health benefits cannot be performed.
• In the case of the USZV employee, the absence of an employee led to non-adherence with allegedly existing internal procedures on accommodation and duration of stay
The Inspectorate is concerned that the absence of one employee has apparently resulted in non-adherence to allegedly existing internal “policies” on not only the choice of hotel where the USZV employee stayed during the medical referral but also on the duration of the employees stay abroad, whereby it was established that these procedures resulted both in a different (more luxurious) choice of accommodation and approval of an excessive duration of the referral and – as a consequence – the abuse of available financial means.
Based on the abovementioned, the Inspectorate has made the following recommendations to USZV:
1. To draft, submit for approval and implement clear policies and procedures for the medical referral of USZV employees abroad, which policies are to include strict adherence to the principles that medical referrals can only be done by locally established specialists (or GP’s).
2. Have an audit performed on the necessity of medical referrals of USZV employees in the past 2-3 years whereby – in any way and not restricted to – the necessity of the referral abroad itself, the necessity for the duration of the referral and the arranged type of accommodation are investigated and – in case of established abuse – it is investigated if unnecessary expenditures can be recovered from the concerned employees.
3. Establish a proper monitoring and tracking system and procedures not only for ZV and other patients but also for all USZV employee referrals, including medical information, lodging, and expenses.
4. Ensure that local (referring) specialists and specialists abroad are able to communicate directly in order to exchange medical information on a patient and keep patient files up to date. Upon return, the medical file from the specialist abroad must be made available to the local treating specialists and GP.
These conclusions and recommendations will be added to the final audit report.
Source: St. Martin News Network
Inspectorate investigated possible non-optimal procedures and abuse in two medical referral cases