Investigation reveals SZV has no policy for referrals of its staffers

~ Best says this ‘promotes fraud’ ~

PHILIPSBURG–The findings of an investigation conducted into the medical referral of a Social and Health Insurances SZV staff member has found that there is no evidence of the existence of any approved regulation, written policy or procedure for the medical referral of SZV employees.

The findings were the result of one of two investigations into medical referral cases conducted recently by the Inspectorate of Public Health.

Inspector General Dr. Earl Best said on Sunday that the Inspectorate “is deeply concerned” about the absence of a written and approved regulation and procedure for medical treatment (and referrals) for SZV employees and their family members. “As a result of this, the [SZV – Ed.] 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 written procedures and policies promotes fraud and 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.

Best said there was no documentation available for the SZV employee in question that justifies the necessity of the medical referral itself, the need for the 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 SZV employee might have been sent to Curaçao unnecessarily and remained there at the expense of SZV for a much longer period (three to four times as long) than required.

The Inspectorate is aware of the fact that the funds used by SZV are not directly regulated in 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,” Best said in a press release.

“In the case of the medical referral of the SZV employee, no report was received from the specialist abroad nor was the Inspectorate informed that such a report was due.”

Best said under normal circumstances, where a patient is referred abroad by a local medical specialist via SZV’s medical referral department, it is expected of the specialist abroad to report back to SZV about the diagnostic or therapeutic results. This report can also be used by SZV 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 evaluation of both the need for the referral and the acquired health benefits cannot be performed, Best said.

In the case of the SZV 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 SZV employee stayed during the medical referral, but also on the duration of the employee’s 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.”

Best issued several recommendations to SZV. These include drafting and submitting for approval and implementation, clear policies and procedures for the medical referral of SZV employees abroad, which are to include strict adherence to the principles that medical referrals can only be done by locally established specialists or general practitioners.

The Inspector General also recommended that SZV have an audit performed on the necessity of medical referrals of SZV employees in the past two to three years where 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.

SZV was also advised to establish a proper monitoring and tracking system and procedures not only for ZV (one of the insurance funds falling under SZV) and other patients, but also for all SZV employee referrals, including medical information, lodging and expenses.

“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 general practitioner,” Best recommended. These conclusions and recommendations will be added to the final audit report.

Best said the Inspectorate had planned to audit SZV’s Referral Department and in anticipation of this audit, decided to investigate two cases that were highlighted in the media, including the case of the SZV staff member.

The other case involves a ZV insured patient that had to be flown out urgently. SZV spends approximately NAf. 30 million annually on medical referrals and Best said “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.”

While the report on the case of the SZV employee has been finalised, the Inspectorate hopes to conclude its investigations into the other case “on short term.”

Source: The Daily Herald