The FINANCIAL — During the past seven months the Medical Mediation Service of Georgia has received 6,536 complaints and 53 actions which included GEL 3,516,932.49 worth of financial disputes.
The FINANCIAL — During the past seven months the Medical Mediation Service of Georgia has received 6,536 complaints and 53 actions which included GEL 3,516,932.49 worth of financial disputes. Sixty-nine percent of the disputes ended in conciliation. In most cases, the clinics are the plaintiffs and insurance companies the defendants. The majority of disputes are about late remuneration.
“The number of complaints dramatically increased in January,” said the Head of the Medical Mediation Service. “None of our recommendations or conclusions have been appealed against by any side which is very important. The Service is tailored to reach agreements. All the terms which are connected to presenting the report or compensation are regulated by the 177th decree. From now on when insurance companies say that clinics are not providing documentation properly or on time it will not be an adequate reason for delaying compensation. In most cases disputes are about the non-fulfilment of recognized obligations from the side of the insurance company. We have not yet come across a case where an insurance company is appealing against a clinic,” she said.
Experts explain that in some cases doctors deliberately scam their patients and the insurance companies to get more profit. “Providing or prescribing excessive medical treatment is a good example of such scamming,” said Giorgi Gigolashvili, President of the Insurance Institute of Georgia. “Sometimes doctors sell additional services to patients. The research proves that there are a high number of cases of excessive drug use. In such cases the insurance company pays for no reason and runs its business at a loss. At the same time if an insurance company has some problems with the clinic, then the doctors will put off treating its insured patients. Doctors complicate the treatment procedures for such patients. For example, they might force the patient to wait in a queue unnecessarily” he added.
“Out of the multitude of problems at the clinics I would single out drug corruption as the main challenge we face,” said Nino Kobakhidze, Managing Director at Gras Savoye Georgia. “The doctors are dealing with pharmacy companies. I have noticed that patients are sent for laboratory examinations very often without good reason. As the clinics are afraid of losing patients they agree to such non-profitable offers from the insurance companies such as low compensation for their doctors. Doctors who work at state clinics should prefer to receive insured patients as they are guaranteed payers. But herein lies another problem – some insurance companies pay well and some do not. That then reflects on service quality. If a patient comes from a good payer insurance company, he/she is treated well enough. If not, then the patient is not treated properly,” she added.
This risk of being deceived is high when an insured patient visits a clinic which is not the provider clinic of the same insurance company where he/she is insured. “In this case a patient is asked whether he/she is insured or not. In the event of a positive response doctors exceed the treatment as they know that the insurance company will pay for it for sure. Of course insurance companies check the documents but very often do not find signs of fraud. I cannot understand why the insurance companies do not come down hard on such issues, especially as it results in loss for the company,” Kobakhidze said.
The research by Transparency International Georgia shows that the involvement of pharmaceutical companies in the hospital sector’s ownership and management is a potential source of conflict of interest. According to some sources, in some hospitals, preference is given to the medicines imported or produced by the relevant pharmaceutical company. There are insufficient institutional arrangements that guarantee the quality of services and patient rights. At the same time, low wages of medical personnel and the lack of protection for their rights are a problem, especially in the regions, proves the study.
GPI Holding officials explain that when it comes to the many problems with the medical institutions they prefer to solve them instead of appealing against the clinics. “Prescribing unnecessary medicaments and extra analyses are common contraventions from the medical institutions’ side. We do not appeal against them however, as we tend to find such errors in time and thereby prevent them,” a GPI Holding official said.
Discussion about this post