Health insurance fraud in the Dutch healthcare system : a sociological approach to fraud in healthcare

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A Sociological Approach to Fraud in Healthcare

Health Insurance Fraud in the Dutch Healthcare System

Master Thesis in Sociology

Comparative Organization and Labour Studies Nicolette Haasnoot / UVA-ID: 11406216 nicolettehaasnoot@hotmail.com

Supervisor and first reader: Dr. J.P. Bruggeman Second reader: Dr. J.J. de Deken

University of Amsterdam Amsterdam, 9 July 2018 Words: 10214

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1 Abstract

Health insurance fraud is a structural problem in the Netherlands that brings high costs every year. While insurance fraud is mostly seen as an act of purposefully being dishonest to benefit from an insurance pay-out, there are also scenarios where healthcare providers intentionally committed an error, because the declaration system of the health insurers would not allow to perform the declaration in the normalised (standard) way. The complex declaration systems of health insurers seems to pave the way for errors and fraud in healthcare (Van Kolfschooten, 2003). Literature on healthcare fraud normally only focusses on policy and technical issues. Little research is done for the implications of social practices which can normalise a certain behaviour (Hyman, 2001). For this reason, this explorative research will dig deeper and analyse the social practices that occur during the declaration process of healthcare providers and how these social practises normalise a certain declaration behaviour that health insurers define as “fraud”.

This thesis provides insight in normalised declaration behaviour of healthcare providers from different backgrounds. The study accounts for several case studies (N=16), using observations and semi-structural interviews with medical specialists who work in hospitals and/or private clinics, dentists, general practitioners and a psychologist.

The study finds that several social practices like: dysfunctional declaration norms, conflicting social norms between healthcare providers and health insurers, and shared beliefs in the social network of healthcare providers normalise the declaration behaviour of

healthcare providers.

The results can contribute to a better understanding of the high costs in healthcare and demonstrate that certain declaration norms of health insurers are dysfunctional in work practice. This mismatch between the declaration system that health insurers offer and the work practices of healthcare providers, results in a certain declaration behaviour among healthcare providers that health insurers define as ‘fraud’.

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2 Content

Chapter 1- Introduction ... 3 1.1 Background ... 4 1.2 Purpose ... 6 1.3 Research Questions ... 6

Chapter 2- Literature Review ... 7

2.1. The Dutch Healthcare System ... 7

2.2. Healthcare Fraud ... 8

2.3. Social Norms and Practices ... 9

2.4. Breaking Rules and the Normalisation of Behaviour ... 10

Chapter 3- Research Design ... 11

3.1 Methodology ... 11 3.1.1. Data Collection... 11 3.1.2. Data Analysis ... 12 3.1.3. Trustworthiness ... 13 3.2 Operationalisation ... 14 3.2.1 Demarcation ... 15 Chapter 4- Results ... 16

4.1 Observation and Interview Report ... 16

4.2 Interview Results ... 17

4.2.1 Work Routines and Practices of the Declaration Process ... 17

4.2.2 Social Network of Healthcare Providers that Effect the Declaration Process ... 19

4.2.3 Social Norms and Social Meanings Embedded in Organizational Culture ... 20

4.2.4 Declaration Behaviour of Healthcare Providers and Legitimization of their Actions ... 21

4.2.5 Opinions about Formal Norms, Expected Behaviour, and Bureaucratic Rigidity ... 22

Chapter 5- Conclusion ... 25

References ... 28

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3 Chapter 1- Introduction

Health insurance fraud is a structural problem in the Netherlands that brings high costs every year. The umbrella organization of healthcare insurers in the Netherlands (Zorgverzekeraars Nederland, 2017) detected that 24,8 million euro of healthcare costs is incorrectly declared in 2016. From this 24,8 million euro, 18,9 million euro (76%) is lost by insurance fraud

(appendix). 37% of this insurance fraud is done by healthcare providers (appendix) by falsifying bills and making claims for interventions that did not take place (Zorgverzekeraars Nederland, 2017). Insurance fraud is mostly seen as an act of being purposely dishonest to benefit from an insurance pay-out. The health insurers of the Netherlands speak of fraud when ‘an error has been intentionally committed and a certain advantage has been obtained’

(Zorgverzekeraars Nederland, 2017).

But what if an error has been committed intentionally because there was no other option? The complex declaration systems of health insurers seem to pave the way for errors and fraud in healthcare (Van Kolfschooten, 2003). There are scenarios where healthcare providers committed an error on purpose, because the declaration system of the health insurers would not allow to perform the declaration in the normalised (standard) way, by for example missing codes for certain work practices. This mismatch between the declaration system that health insurers offer and the work practices of healthcare providers, results in a certain declaration behaviour among healthcare providers that health insurers define as ‘fraud’.

This thesis is concerned with how these healthcare providers normalise a certain declaration behaviour in the Dutch healthcare system. It will focus on the social practices that occur during the declaration process of healthcare providers. The current chapter introduces the research topic further and establishes the purpose of this thesis. The second chapter will present a literature review of rule violations and how healthcare providers normalise certain behaviours. The third chapter discusses the research design and the actual execution of this study. Chapter four presents the results of the data that is collected and these results will be analysed and associated with the literature. Finally, the conclusions of this research will be discussed in chapter five.

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1.1 Background

The core theme of this research is health insurance fraud done by healthcare providers that have been falsifying bills and making claims for interventions that did not take place. The Dutch health authority (hereinafter referred to as NZa) defines fraud by three criteria: The violation of the declaration rules, an (financial) obtained benefit, and an intentional act. The Fraud Detection Expertise Center (FDEC), who researches irregularities in health declaration files, has trouble with this definition of fraud. They mention that people have different views about the meaning of fraud, and it is in not immediately clear what exactly is meant by fraud (Kersten & Kowalczyk, 2014). The association of general practitioners also complained in a letter addressed to the minister for health about the broad definition that the NZa uses: “the NZa ignores the daily medical practice of a very complex healthcare system . . . the term fraud should therefore be used with great restraint in the light of the complexity and (im)possibilities of our care system” (Vereniging Praktijkhoudende Huisartsen, 2013, p.1). There is a mismatch between the definition that the NZa and health insurers use for fraud and the work practice of healthcare providers who have to deal with a complex declaration system. The next section will provide more information about the declaration system of the health insurers.

The healthcare providers declare the costs of the provided treatments of patients in complex electronic declaration systems of the health insurers. These systems use the so called “AGB- specialism codes” which identify the healthcare provider and the authorizations of the specialism. The AGB- code gives access to different digital processes which depend on the specialism and authorities of the healthcare provider. The healthcare provider has to declare costs in either codes for healthcare products, or in a Diagnosis Treatment Combination (hereinafter referred to as DBC), which is the complete treatment of a patient (Nederlandse Zorgautoriteit, 2017). The DBC- declaration structure has however very complex and

extensive regulations which makes the declarations that are done unclear and hard to control. There are over five thousand codes for DBC’s, which all have their own specifications (Nederlandse Zorgautoriteit, 2016).

Also the high status and great autonomy of healthcare providers makes it harder to ask accountability for their actions and full control on fraud is usually missing. Healthcare providers have to account for their work by filling in forms, but little is done with the collected data. This all improves the opportunity for healthcare providers to commit fraud (Groot, Maassen & van den Brink, 2014). The complex declaration system of the health

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insurers seem to beget errors and fraud in healthcare, but there are also scenarios where

healthcare providers committed errors on purpose, because the declaration system of the health insurers would not allow to perform the declaration in the normalised (standard) way. This is illustrated in the following interview fragment:

In a conversation with a gynaecologist it becomes clear that the complex declaration system results in a certain declaration behaviour among healthcare providers that health insurers define as ‘fraud’. The gynaecologist tells that certain treatments do not ‘validate’ because there is no existing declaration code where he is authorized for. Sometimes fractures occur during a surgery that need to be repaired. The

gynaecologist is not authorized in the declaration system to repair fractures because this is the task of a surgeon. However, the gynaecologist has the expertise to repair the fracture, so he decides to do the treatment anyway. Because the gynaecologist cannot declare the treatment he has done, he decides to commit fraud and declare a treatment which is comparable in costs, otherwise he will not earn money on the treatment at all. “The rigidity of the system is something I do not understand. I am a doctor and I am educated to perform this treatment, but only because there is no code for it, it cannot be done” (personal communication, May 12, 2017). The gynaecologist violated the declaration rules, gained a benefit out of it (getting paid, instead of not getting paid) and it was an intentional act. He admits that he committed fraud but seems to

legitimize his act by saying that it is purely for the hospital and that it does not provide a personal benefit (personal communication, May 12, 2017). The gynaecologist

committed fraud because it was necessary to provide a good quality of care. If he decided not to commit fraud, he had either called in a surgeon to repair the fracture, what would have cost a lot of time and money (which is against the norm of insurers to be cost conscious) or he should have repaired the fracture himself without making a declaration, so there would be no revenue, only extra costs for the hospital (personal communication, May 12, 2017).

Fraud in healthcare is all about the intentional act of violating the declaration rules and obtaining a benefit out of it. Rule breaking is generally seen as deviant behaviour of self-interested or angry employees who do not identify with the organization (Morrison, 2006). The gynaecologist committed fraud for the quality of the healthcare and the well-being of the hospital. The act of breaking the declaration norm for the financial well-being of the hospital indicates a strong identification of the gynaecologist with the organization. He legitimized his

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own action by saying he did not commit fraud out of self-interest. He normalised his own behaviour by allowing exceptions to the norm on fraud, because it was for the greater good. His rule breaking motive is more social than rule breaking normally is seen according to Morrison (2016). Literature on healthcare fraud normally focusses only on policy and technical issues. Little research is done to the implications of social rule breaking practices which at the same time normalise certain behaviour (Hyman, 2001). For this reason, this explorative research will dig deeper and analyse the social practices that occur during the declaration process of healthcare providers and investigate how these social practises normalise a certain declaration behaviour. This will be done by several case studies from healthcare providers of different backgrounds.

1.2 Purpose

The purpose of this research is to investigate the social practices that occur during a

declaration made by a healthcare provider and examine if these social practices normalise the declaration behaviour of healthcare providers in what would be called ‘fraud’ by the health insurers. The study will focus on how healthcare providers develop or learn a certain

declaration behaviour, and how they know when, and in which way declaration norms can or must be violated. Insight in normalised declaration behaviour can contribute to a better

understanding of the high costs in healthcare and demonstrate that declaration norms of health insurers are dysfunctional in work practice.

1.3 Research Questions

In order to investigate the social practices that occur during the declaration process of

healthcare providers, the following research question and sub-questions have been formulated for this research:

• Which social practices normalise the declaration behaviour of healthcare providers in the Dutch healthcare toward insurance fraud?

o Which social practices are involved in the declaration process of healthcare providers?

o What are the current norms for the declaration process and what kind of errors form the mismatch?

o How do healthcare providers normalise or get socialized in a certain declaration behaviour?

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7 Chapter 2- Literature Review

This chapter will present a review of the social practices that could influence the declaration behaviour of healthcare providers. The next section will start with a brief explanation of the Dutch healthcare system and the recent developments and peculiarities that healthcare providers have to deal with. The second section will discuss the concept of healthcare fraud and its characteristics. The third section is about social norms and practices that occur in the healthcare sector and the last section will focus on normalisation, rule breaking behaviour and organizational deviance.

2.1. The Dutch Healthcare System

The current healthcare system of the Netherlands is based on four system laws, whereof the Health Insurers Act (hereinafter referred to as Zvw) is the main law. In the Zvw every Dutch citizen is insured for a basic healthcare package provided by private health insurers. The implementation of the law is performed by regulated market forces (regulations established by the Dutch government) wherein private health insurers and healthcare providers compete with each other. Health insurers can influence the efficiency and quality of the healthcare provided by purchasing healthcare by means of (selective) contracting with healthcare providers (Ministerie van Volksgezondheid, Welzijn en Sport, 2016).

The regulated market forces have some consequences in the Dutch healthcare. Healthcare providers have to deal more and more with protocols and the documentation of their labour. They also have to cope with diverse parties that all have different interests: the management of the hospitals, the health insurers, the government and the patients. These parties ask for high performances, an improvement in quality of the healthcare, and at the same time cost efficiency (Tonkens, 2008).

Cost efficiency is necessary because of the continuous growing healthcare costs. In 2016 the total healthcare expenditure was around 97 billion euros (Centraal Bureau voor de Statistiek, 2017). The healthcare costs keep growing because of the increased life expectancy, the aging population, an increase in the number of chronically ill, and expensive medical-technological developments (Rijksoverheid, 2018). The healthcare sector is increasingly standardized by prescribed rules and protocols to keep the rising healthcare costs under control and to improve the quality of healthcare by preventing medical errors. There is an extensive bureaucratization and this results in an administrative burden wherein healthcare

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providers continuously have to account for all the work performances they do (Tonkens, 2008). Medical specialists state that up to 40% of their time is taken up by administration of which they regard 4% as useless (Federatie Medisch Specialisten, 2017). Bureaucratic rigidity can encourage the healthcare providers to violate the rules and avoid the standard procedures (Baucus et al, 2008). If the declaration norms are dysfunctional in work practice than this can be a reason for healthcare providers to intentionally violate the rules.

2.2. Healthcare Fraud

The NZa defines fraud by three criteria: The violation of the declaration rules, an (financial) obtained benefit, and an intentional act. It became clear that there is ambiguity about the meaning of fraud. The definition that the NZa and health insurers use for fraud does not match the work practice of healthcare providers who have to deal with a complex declaration system (Vereniging Praktijkhoudende Huisartsen, 2013). The NZa based their definition of fraud on the following definition: “(…) any act or omission, including a misrepresentation, that knowingly or recklessly mislead, a party to obtain a financial or other benefit or to avoid an obligation” (Hussain, 2014, p.21). What is striking about this definition is the “knowingly or recklessly” part. These concepts are vague compared to the definition of “purposely” they use in criminal laws, where there is a strict description of a person’s state of mind and many precise requirements for the burden of proof. The NZa states that the intentionality of fraud is less relevant and that the declaration needs to be in accordance with the laws and regulations (Groot & Maassen van den Brink, 2014).

Fraud mostly takes place in a social network and is ‘social’ whenever multiple people are involved. In a sociological perspective the network and culture wherein fraud exists should be explored. Mostly there is a conflict between the formal norms, “the proclaimed culture” of an organization and the work practices of the personnel “the adopted culture”. An interesting angle of approach would be to look at the loyalties of the healthcare providers. Healthcare providers embrace through history their loyalty to patients and this loyalty can come in conflict with obligated norms of other parties. So to understand healthcare fraud better there should be a focus on the social processes of healthcare providers (Sampson, 2014).

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2.3. Social Norms and Practices

The Ministry of Health, Welfare and Sport (2013) concludes from a risk analysis of fraud in healthcare that there is hardly any pressure from the social environment of medical specialists on the standard declaration behaviour and that there is a lack of normative and corrective behaviour. Especially the social part, the consequences of social norms and practices that influence the declaration behaviour of healthcare providers, should be more studied to have a better understanding of fraud in healthcare. “Professions quite self-consciously develop their own social norms and social meanings, which are inculcated during training and reinforced throughout a provider’s professional life. Many occupations and corporations also develop internal social norms and social meanings, which are reflected in mission statements and corporate culture” (Hyman, 2001, pp. 540-541). Medical professions embraced through history the social norm of loyalty to patients and this social norm comes into conflict with the obligated norm of health insurers to be more cost conscious. When healthcare providers believe that the only way to provide a high quality of healthcare is by violating the declaration rules, than the feelings of shame they might feel for violating the rules will be significantly muted. The social norm conflict between healthcare providers and health insurers results in disagreements about the social meaning of fraud. Where health insurers define fraud as a criminal behaviour, the healthcare providers see the behaviour as necessary to provide a good quality of care to their patients (Hyman, 2001).

Healthcare providers could also be annoyed by the burden of protocols, which they believe are partly unrelated to the healthcare they need to provide. This can result in creating deviant social norms among the whole network of the healthcare providers, which make it difficult to encourage healthcare providers that fraud control is important too. A study of healthcare providers that committed fraud shows the strength of these social norms and meanings (Jesilow et al., 1991). Although the healthcare providers were condemned for fraud, they did not believe that they were in the wrong and blamed the “stupid laws” and

“bureaucratic nonsense”. This subculture developed by the tension between the professional standards of the healthcare providers and the imposed regulations. When healthcare providers deviate from the formal norms, they can use their professional justification that is commonly available in the medical sector to fend off the criminal definition of what they have done (Hyman, 2001).

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2.4. Breaking Rules and the Normalisation of Behaviour

Fraud in healthcare is all about the intentional act of violating the declaration rules and obtaining a benefit out of it. Rule breaking is generally seen as deviant behaviour of self-interested or angry employees who do not identify with the organization (Morrison, 2006). Empirical studies show that rule breaking is socially controlled, because of a high level of agreement about when a rule may be violated (Verkuyten, 1994; Morrison, 2006). This seems the case in the declaration process of healthcare providers. The dysfunctional norms for the declaration process makes the rules irrelevant. Healthcare providers seem to violate the declaration norm with the intention to promote the welfare of the hospital, otherwise there will be no declaration made at all. This is indirectly also out of self-interest, because the welfare of the hospital also has an influence on the job of the healthcare providers. But healthcare providers believe that providing a high quality of healthcare is only possible by violating the rule (Hyman, 2001).

Whenever a healthcare provider intentionally violates formal rules to promote welfare to the organization and its stakeholders, or to better quality for patients, this would be called “pro-social rule breaking behaviour”. Employees that strongly care about their job and have a sense of autonomy, are more likely to break rules. Healthcare providers have a lot of

autonomy in their specialism and also strongly care about their job, since it concerns the wellbeing of people (Morrison, 2006).

Rule breaking has to do with the conflict between informal norms (work routines and practices) and formal norms (expected behaviour in the form of rules and protocols), so employees are faced with competing sets of expectations and social influences. Informal norms are norms that groups adopt to regulate the behaviour of the group members. These norms appear when patterns of activity are repeated in organizations and this creates

consensus about the appropriateness of particular behaviours. Healthcare providers can also create certain group norms for declaration behaviour. When certain declaration errors keep occurring, they will normalise a pattern of declaring treatments which health insurers would define as ‘fraud’. Groups tending to deny deviance by normalising it, because “everyone does it in that way” (Feldman, 1984).

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11 Chapter 3- Research Design

This study is based on a qualitative case study approach and is explorative in nature. This chapter will clarify the research method and techniques that are used. The first section discusses the methodology and the second section presents the operationalisation.

3.1 Methodology

This study investigates important (social) factors that occur during the declaration process of healthcare. It seeks reasons or motives for the way that the declaration process is done by healthcare providers. Therefore the study is focused on gaining a different understanding of a social phenomenon instead of providing statistical evidence, and thus is explorative and interpretative in nature (Verschuren & Doorewaard, 2007). Because the study is about gaining insight in different interpretations and opinions, and the meaning that healthcare providers ascribe to the declaration process, a qualitative approach has been chosen in the form of a case study. The case study obtains insight in how the declaration process takes place in practice, by collecting the data in the natural environment of the social phenomenon, which is in this case the declaration process of the healthcare providers (Verschuren & Doorewaard, 2007;

Migchelbrink, 2016).

There is chosen to make use of source- and method triangulation to improve the credibility of the research and gain sufficient results. Triangulation means that multiple data sources and research methods are used. The source triangulations are (policy) documents and healthcare providers of different professional backgrounds. The method triangulations are observations and semi-structured interviews (Verschuren & Doorewaard, 2007; Migchelbrink, 2016).

3.1.1. Data Collection

The most common methods for data collection in case studies are interviews and

observations, because these methods make it possible to gain a comprehensive understanding of social phenomena (Verschuren & Doorewaard, 2007; Migchelbrink, 2016). For this reason the primary data method of this thesis is semi-structured interviews. Semi-structured

interviews seemed to be the most suitable for this study, because it is a flexible method which provides guidance throughout the interview with a list of several key questions, but also allows for further elaboration of the topics that is important for the respondents. The method allows more deeper insights than a structured interview and gives more guidance than the

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unstructured interviews. The list of interview questions (appendix) is tested beforehand in a first pilot interview with a medical student to check if the interview questions are clear, and if it will be capable to gain good information to answer the research questions (Migchelbrink, 2016; Gill et al., 2008).

Because this study is about fraud in healthcare, there is paid special attention to the introduction of the research to the respondents. Fraud is a sensitive topic for healthcare providers and this can put them at unease that can influence the results. The healthcare

providers could possibly give wrong answers out of self-defence. For this reason the study has been introduced as a reflective research of the health declaration system of health insurers wherein questions will be asked about personal experiences with the declaration process. The respondents are also assured about the anonymity and confidentiality of the research, by pointing out that names and locations will be censored in the thesis, and there is asked for permission for recording the interviews. This will increase the likelihood of honest answers and thereby the credibility of the research (Gill et al., 2008).

Most interviews are done in the natural environment of the declaration process, because first of all the familiarity of the area will relax the respondents, but also for the possibility to do observations. The observations that are done are unstructured and not mentioned to the respondents. A report of the observations is presented in chapter 4.1 and the interview results are presented in chapter 4.2.

3.1.2. Data Analysis

The data of this study is analysed by working out each case individually through listening to the interview records and writing out the relevant results that are needed to answer the research questions. The results of each individual case are sorted on the following topics:

• Work routines and practices of the declaration process

• Social network of healthcare providers that effect the declaration process • Social norms and social meanings embedded in organizational culture • Declaration behaviour of healthcare providers

• Legitimization of their actions

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3.1.3. Trustworthiness

In qualitative research it is hard to prove that your findings are true and accurate. This research has no means to provide statistical evidence or to generalize its findings, but it is focussed at exploring and understanding a social phenomenon by analysing the social

practices of the declaration process. To make the findings more trustworthy, there is chosen to explore the declaration behaviour of healthcare providers of different backgrounds to check if the problem occurs in more medical professions. There is also chosen to analyse healthcare providers who work in hospitals and healthcare providers who work in private clinics, to check if there is a difference. The insights in normalised declaration behaviour can contribute to a better understanding of the high costs in healthcare and be of value for the research area of fraud in healthcare.

Measures have be taken to increase the credibility of this study. There is chosen to make use of source- and method triangulations to have more credible and sufficient results. In the data collection is a precise method adopted, because semi-structured interviews have a lower validity than structured interviews (Migchelbrink, 2016). The interview questions are for this reason operationalized from the literature in chapter 2 by creating a topic list. This operationalization is presented in the next section. The interview questions are tested

beforehand in a pilot interview with a medical student to check if the interview questions are clear and capable to gain good information for answering the research questions. The

interviews are recorded and this records are used for setting up the results. The interviews are not transcribed, because it is time consuming and given the time available it was not feasible. The downside of not transcribing is that information may be lost (Migchelbrink, 2016), and for this reason there are made fieldnotes during the interviews and these fieldnotes are worked out directly after the interviews and observations.

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3.2 Operationalisation

To answer the research questions of this thesis, it was necessary to translate the theoretical concepts into topics and additional observable indicators. These observable indicators are used to set up interview questions that will be able to answer the research questions. The topics are also used for the data analysis.

This study is concerned with the normalisation of a certain declaration behaviour (violating the declaration rules) in the declaration process of healthcare providers. The main concept is therefore the ‘declaration process’. In the literature review it became clear that rule breaking has to do with the conflict between informal norms (work routines and practices) and formal norms (expected behaviour in the form of rules and protocols). Healthcare

providers are faced with competing sets of expectations and social influences. For this reason the theoretical concept ‘declaration process’ is divided in the two components ‘informal norms’ and ‘formal norms’. These components are divided in variables. For ‘informal norms’ the following variables are used: ‘social practices’, ‘loyalty’ and ‘normalisation’. For ‘formal norms’ the variables: ‘definition of fraud’ and ‘declarations norms’ have been used. Every variable is translated in observable indicators.

Declaration process Informal norms Social practices Work routines and practices Social network Loyalty Social norms and social menaings Normalisation Declaration behaviour Legitimization Formal norms Definition of fraud Declaration norms Expected behaviour Bureacratic rigidity Protocols

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The observable indicators are translated into interview questions:

3.2.1 Demarcation

Semi-structured interviews and unstructured observations are done with healthcare providers from different backgrounds (N=16). The reason to choose healthcare providers from different backgrounds is to explore if the normalisation of declaration behaviour occurs in different areas of the Dutch healthcare and to analyse if some specialists experience more problems than others. The respondents are selected by theoretical sampling, which means that the respondents are selected by considering their profession but also their availability. The reason for this is that healthcare providers are hard to reach and therefore you are dependent of your own social network, but they are selected from as many different backgrounds as possible. There is chosen to select healthcare providers who work for hospitals and healthcare providers who work for a private clinic, to analyse if the same problems occur in these different work environments. The following respondents are interviewed:

• 4 dentists (2 general dentists, 2 specialized dentists)

• 3 anaesthesiologists (they all work for the hospital and for private clinics) • 2 gynaecologists (hospital)

• 2 general practitioners (private clinics) • 3 ophthalmologist in education (hospital) • 1 psychologist (private clinic)

• 1 dental surgeon (hospital and private clinics)

Pertinent Interview Questions Indicators Variables

• How much time do you spend on healthcare declarations? • Are you satisfied with the declaration system? Why?

-Work routine & practices -Social practices • Do you ever have problems with healthcare declarations?

If so, what kind of problems?

• Do you find the declarations standards from the health insurers workable in practice?

• Do you adhere to the declaration standards? Why?

-Social norms and meanings -Bureaucratic rigidity -Expected behaviour -Protocols

-Loyalty

-Declaration norms

• Have you learned how to make healthcare declarations by yourself, or (used tips) from others? Who?

• What do you do if a declaration does not fit into the health insurance provider's declaration schedule?

• When you run into a problem in the declaration process, how do you solve it? (creative solutions?)

-Social network -Declaration behaviour -Legitimization

-Social practices -Normalisation

• Do you think that the declaration system should improve and what improvements would you recommend?

• Do you have something important to add that has not been dealt with concerning the healthcare declarations?

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16 Chapter 4- Results

The collected data is extracted from observations of the declaration process and from interviews with healthcare providers from different backgrounds (N=16). In this chapter the results are presented that are relevant to answer the research questions. The first section will present an interview- and observation report. The second part of this chapter will present the relevant information, divided in topics, that is collected from the individual interviews.

4.1 Observation and Interview Report

Note: it was hard to make appointments with the healthcare providers. They are really busy and hard to reach. Nine interviews were done at the natural environment of the healthcare providers. Four interviews were done at the home of the healthcare providers and four interviews were done by a telephone conversation. These interviews had less time pressure than the interviews done in the hospitals and private clinics, where there was more time pressure and some interruptions.

The interviews are introduced as an reflective research to the health declaration system of health insurers wherein questions will be asked about personal experiences with the

declaration process. The respondents are also assured about the anonymity and confidentiality of the research, by pointing out that names and locations will be censored in the thesis, and there is asked for permission for recording the interviews. All interviews went well, except one interview. The first interview was with a dentist who knew that this study is about fraud and she was very defensive in her responses.

During some interviews the healthcare providers showed part of the declaration system where they have to declare the provided treatments. Notable was that not every healthcare provider used the same type of declaration, but every declaration had a ‘grouper’ checking the validity automatically. The healthcare providers were not happy about this grouper system because whenever one little mistake occurs, like a misspelled name, the declaration would be rejected before it arrives at the health insurer.

The declaration system of the health insurers uses codes. When healthcare providers type in a diagnosis, the system will select automatically a DBC (Diagnosis Treatment Combination) which fit the diagnoses. An ophthalmologist in education showed that sometimes when she used another word in her diagnoses then the system is used to, there were no results. She just learned the declaration process and still had to learn the terms of

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diagnoses that the system uses. A dentist showed that her declaration had become a sort of routine and that she knew almost every code out of her head.

During an observation in the hospital in the personnel’s office it was notable that healthcare providers (in education) asked each other for help when they got stuck in a

declaration. An ophthalmologist in education asked her colleague which DBC she could best use for a certain diagnosis. It was the end of the day, and every healthcare provider still had to do their declarations and administration. A gynaecologist also complained about all the administration he still had to do on the end of the day, because he doesn’t have time for it during the day. This is because of the protocols for a patient conversation that may not take longer than 10 minutes.

During another observation, which took place in the operation room of a private clinic, healthcare providers were complaining to each other about health insurers who do not approve certain declarations. They had to fill out a lot of forms and they made mutual agreements with each other about which treatment hours they would declare for certain patients. These where not the exact treatment times, but they charged exactly 2 hours per patient, so that the health insurer wouldn’t object. Health insurers object when treatment times take longer than three hours, so the medics were creative by charging two hours for one hour treatments of some patient, and two hours for three hour treatments of others.

4.2 Interview Results

The results of the individual interviews are sorted and divided in topics, which are presented below.

4.2.1 Work Routines and Practices of the Declaration Process

The work routines and practices of the declaration process differ among the healthcare providers. The medical specialists (anaesthesiologists, gynaecologists, ophthalmologists and dental surgeon) declare the provided healthcare in Diagnosis Treatment Combinations

(DBC’s). The medical specialists have a full planning during the day, and for this reason they save their declarations for the end of the day or the end of the week. The healthcare

declarations do not have any priority for them. It is an extra administrative task that needs to be done. The DBC- systematic is very complex, because of the quantity of different

diagnosis’s a medical specialist can make. There does not exist a DBC-code for every possible diagnosis, and for this reason the medical specialists have to be creative in finding a

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suiting DBC for the diagnosis that is made. The medical specialists complain about the

“grouper” system that checks the declarations automatically before it goes to the health insurer. When little mistakes are made, the declaration will be send back to the healthcare provider and this causes a lot of work and frustrations.

• Ophthalmologist 1: “We put a main diagnosis in the declaration system and

automatically a DBC will be connected. But sometimes I have a main diagnosis where no code for exists, and then you have to make the best out of it. Then you have to find a diagnosis which is similar or put in the system something vague, like: condition not further described.”

• Ophthalmologist 2: “It’s extra work. Sometimes you forget to put a declaration in the system and then you get a reminder. Last week I got a reminder that I still had 40 or 50 declarations to make. That took some time and we already have a lot of

administration (. . .) DBC’s have the lowest priority for us. There is so much to do, so if they don’t remind you, you will forget.”

• Ophthalmologist 3:“You have a report of your diagnosis in the dossier and there you can find back what you did with the patient. On another moment you put it in the system. It is an extra task to do and it doesn’t mean anything for us, except the money, but we don’t see that.”

• Anaesthesiologist 1: “Sometimes doctors have no time or they are not in the mood to make declarations, and then they don’t make any declarations at all. Most doctors think: I declare nothing because then it won’t go wrong. When a declaration goes wrong, you get it back and you have to do more work.”

• Anaesthesiologist 2: “You can fill in every form and every declaration, but if the declaration system does not have codes for it, than you do all your work for nothing”. • Anaesthesiologist 3: “I have to make sure that all my codes are correct, otherwise the

health insurers can call it fraud. So before surgery every code needs to be checked, but sometimes codes do not exist.”

The dentists, general practitioners and the psychologist declare healthcare in codes for healthcare products. They have less problems with codes that do not exists, because every healthcare product has a code. For this reason it is easier for them to make a routine out of the declaration process. Still there are problems they have to deal with. Some codes cannot be combined with each other. When this problem occurs, the healthcare providers have to think of a creative solution. There are also declaration norms from the health insurers that create

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problems. It is not allowed to make two declarations per day, per patient. However,

sometimes it is necessary for a patient to come back later that day for a treatment that is urgent. In this case the healthcare providers cannot declare the costs they made.

• Dentist 1: “I know every code out of my head and the declaration system has shortcuts for codes, so that is pretty fast, easy and it gets a routine.”

• Dentist 2: “I think the declaration process is finetuned the last years. It’s easy and transparent for us, the insurer and the patient.”

• Dentist 3 (specialist):“Treatments that are turned down by the health insurer cost the most time in the declaration process.”

• Dentist 1: “Sometimes when you declare more codes, the system gives an error

because some codes can’t be made together. When this happens you remove one code, or you make another combination of codes.”

• General practitioner 2: “Sometimes you ask a patient to come back the same afternoon, but then you get a problem, because you are not allowed to declare two treatments on one day. If you declare two consults, one will be turned down by the health insurer. You have to keep this in mind and plan the patient on another day instead.”

4.2.2 Social Network of Healthcare Providers that Effect the Declaration Process

Every healthcare providers mentions that they use their social network (mostly colleagues) to discuss the declarations process. They ask each other for help and share ideas and techniques of how they do their declarations.

• Dentist 1: “We discuss declarations. We discuss the costs of certain treatments. For example a dental crown, it is very expensive and you need to make a lot of x-ray photos for it. Sometimes it is hard to decide if you declare the photo, because it doesn’t really feel fair for the patient since the treatment is already so expensive. So you discuss with colleagues how they do that, do they charge the whole amount?” • Dentist 2: “I had trouble with learning how the declaration system works. I asked my

colleagues for advice and other dentists who work in other clinics.”

• Ophthalmologist 2: “Often I cannot find a diagnosis in the system, and then you have to think which other diagnosis fits the best with your diagnosis. Mostly I ask my colleagues for help: how would you put it in the system?”

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• Psychologist: “The declaration process is being discussed a lot with colleagues. The

most time goes to the contract procedure with health insurers. Then you have to read all the protocols and rules of the health insurers, and they all differ from each other.”

4.2.3 Social Norms and Social Meanings Embedded in Organizational Culture

The healthcare provider mention that the declarations they have to make is not a priority for them, but an extra task that needs to be done.

• Anaesthesiologist 1: “Sometimes doctors have no time or they are not in the mood to make declarations, and then they don’t make any declarations at all. Most doctors think: I declare nothing because then it won’t go wrong. When a declaration goes wrong, you get it back and you have to do more work.”

• Ophthalmologist 3: “I don’t think it is something I would ask a colleague, but I’ll just choose something which is similar to the diagnosis I made. It is something you have to do fast in between your work and you don’t really make a point out of it.”

• General practitioner 2: “Health insurers often ask for an explanation for declarations. We have a lot of patients who come with request forms for the health insurers for products like: a higher bed, a wheelchair etc. In total there are around 150 request forms and this takes a lot of time and administrative pressure. But you have to do it, because you don’t want to leave your patient in the cold.”

All the healthcare providers share the opinion that the interest of health insurers isn’t

necessary the quality of healthcare, but saving costs. Most healthcare providers mention that the influence of health insurers can be frustrating, because they limit the medicals in how they do their job. It becomes very clear that the healthcare providers are not interested in saving costs, but their interest is helping the patients.

• Gynaecologist 2: “Health insurers decide which treatments they cover. Sometimes they do not cover treatments that are proven to work very well. This is very frustrating for us, because you want to help the patient, but you can’t, only because the health insurer doesn’t cover the treatment.”

• Gynaecologist 1: “It is really frustrating when you have a patient where you know of that you can help him, but you can’t because the health insurer does not cover the treatment. Than you have to tell the patient, sorry I have a treatment, but I am not allowed to do it, because it is not covered. And when treatments are not covered by the

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health insurer, you are not allowed to do it in the hospital. This is really frustrating, especially when the treatment worked with a patient very well, and suddenly you cannot do it anymore. The only thing you can do is tell the patient to go to a private clinic to get the treatment, which they have to pay by themselves.”

• Anaesthesiologist 2: “There are different interests. The medical specialist wants to help the patient and the health insurer wants to cut costs. Of course the health insurer also wants a good quality of healthcare, but when they won’t cover treatments

whereof is proven they work very well, then I can only see it as a hidden cost cut over the dead body of the patient.”

• Anaesthesiologist 3:“The health insurers have a whole different interest than the doctors. Doctors want the best for their patient and health insurers want to save money.”

4.2.4 Declaration Behaviour of Healthcare Providers and Legitimization of their Actions

Every healthcare providers mentions that they have to be creative with certain declarations. Some of them acknowledge the creative solutions as fraud. Others legitimize their behaviour by saying it is not fraud, but a different way to get your money.

• Dentist 1: “Sometimes when you declare more codes, the system gives an error because some codes can’t be made together. Those are combinations that are not allowed to be made together. When this happens you remove one code, or you make another combination of codes. (…) For example, a dental cleaning cannot be declared together with an x-ray photo and an incidental consult. An incidental consult is very general and can only be combined with an photo. But sometimes you don’t know the cause of the pain complaint and you have to do more like a dental cleaning. Then you can use an endological consult, which is focused on root canal treatment, because this code is allowed to be combined with more other treatments. You did not commit fraud by this, but putted it under a different name.”

• Dentist 2: “I have problems with the code for giving instruction about oral hygiene, because patients easily refuse to pay for the instruction. So most of the times I do not use this code. But when I give a patient a dental cleaning of about 8 minutes, and I also gave instruction about oral hygiene, then I mostly charge 10 minutes of dental cleaning. This can be better explained to the patient and this is in my eyes no fraud, but declared in another kind of way.”

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• Dentist 3: “I know exactly what to fill in so that the declaration will be approved by

the health insurer.”

• Dentist 4: “Sometimes you need to be creative with your declarations, I mostly use time rates (. . .) Sometimes I spend time with children to make them get used at being at the dentist. Then I don’t declare a time rate but I declare a code for prevention or instruction, while this is not exactly where the code is made for. But we use it and it will be on the invoice, but because the kids are under 18, they will not see the invoice. It goes directly to the health insurer. We never heard anything of it, but I wouldn’t be surprised if we ever hear something of it. Otherwise you have to use the other time rate codes which costs a lot more of work and time.

• Anaesthesiologist 1: “You need to be creative, you need the money, otherwise the company will go bankrupt.”

• General practitioner 2: “Sometimes you have to be creative, but randomly. One time you declare it like this, the other time you do it in a different way.”

• General practitioner 2: “Sometimes you have a patient that you didn’t see but you spend a lot of time on the patient, by calling hospitals or nursing homes. There is no code for that, but it costs a lot of time, sometimes hours. Then I declare a consult with the result that the patient complains at the health insurer that he didn’t have a

consult.”

• Ophthalmologist 3: I have no idea how much money is connected to a DBC. And this is also not discussed. But probably the coordinator or medical knows about it. You only look at the diagnosis and what is most close to your diagnosis. You have no idea if one diagnosis pays more than the other.”

• Gynaecologist 1: “Sometimes the system says: that code doesn’t exist. Then you have to commit fraud and say, well it was another treatment, otherwise you don’t get any money for the work you have done. This rigidity of the system is hard to understand. Just because there is no code for it, your treatment does not exist.”

4.2.5 Opinions about Formal Norms, Expected Behaviour, and Bureaucratic Rigidity

Every healthcare provider (except some general dentists) mentions that the declaration system brings a lot of extra work. This leads to a lot of frustrations.

• General practitioner 1: “A lot of declarations won’t be approved and this creates a lot of frustrations with general practitioners. Sometimes it is about something really small, like a wrong address of the patient, and the health insurer will send it back and

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YOU need to fix it. This is the task of the health insurer, because you did your job and gave the healthcare that was needed, so they need to pay you. The health insurer just says, it is your problem that you won’t get your money, you need to fix it. That is easy for them and extra work for us.”

• Dentist 3: “You have to find out on your own how the declaration system works. With some treatments you need to ask approval to the health insurer, but you also want to help the patient quickly. Sometimes I help patients before I have an approval of the health insurer, because it takes so much time to get a reaction. Then you try to reach the health insurer to ask how long it will take, but this is impossible. It is really hard to find someone the answer your question, stupid system.”

• Dentist 4: “The permissions of treatments of people with a disability have a validity of one year. It costs a lot of time to ask a new permission, and people with a disability won’t be cured. The disability won’t go away, so why do I need to ask permission again every year?”

• Anaesthesiologist 1: “When the system (grouper) approves, sometimes a patient get a message from the insurer that they will not pay it, and that is after a long time. That is really annoying, because the system already approved, and then weeks after the treatment you’ll hear it’s not good and you have to fix it, it all costs time.” • Gynaecologist 1: “We have to do more and more tasks which are not related to

medical work, like administration and declarations”.

• Anaesthesiologist 1: “The declaration system brings a lot of administrative tasks that drive you crazy. You have to do a lot to get your money.”

Most of the healthcare providers have the opinion that health insurers have to much power. They think that health insurers decide things that are not of their concern and share the opinion that it is not their job.

• Dentist 2: “health insurers decide what you can and cannot declare, and this is in my opinion not good. You can try to discuss it with them, but they will not approve. So you have to make sure that you declare less, otherwise you will get it back and this is a lot of work. The health insurers have influence in what you do and how you do your treatments, this is a bad development.”

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• Psychologist: “I find it absurd that you have to ask the health insurer for permission

when a patient has two diagnosis’s. It isn’t the case that when you break your leg two times, that you have to ask permission to the health insurer for the second time

gypsum. So when a patient has anxiety and depression, which is very common to occur at the same time, you have to ask the health insurer for permission and they will ask questions about the content of the diagnosis. This is something I don’t want to tell to the health insurer, because it is private information and not of their concern.” • Psychologist: “Sometimes you need more time with a patient and you want to start a

second treatment. You have to ask the health insurer permission for this, and most times the patient will be moved to another psychologist. This is absurd, because I invested time in that patient to build up confidence, and then the patient has to start over with another psychologist, which will take more time.”

• Dental surgeon: “The humanity of health insurers disappears. I have the feeling that they only care about making money and profit.”

• Psychologist: “The contracts are not good. I get that they want to improve the quality of healthcare, but this is not the job of health insurers. They have to take for granted that we do our job well, with inspection and instructions of the healthcare sector. The healthcare sector has regulations for the quality of the healthcare, but the health insurers add their own rules to that. That creates a lot of extra work for healthcare providers.”

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25 Chapter 5- Conclusion

In this chapter the research question and sub-questions will be answered, by making a connection between the results and the theory.

Which social practices are involved in the declaration process of healthcare providers?

Medical professions embraced through history the social norm of loyalty to patients and this social norm comes into conflict with the obligated norm of health insurers to be more cost conscious (Hyman, 2001). This clearly comes forward in the results of the healthcare

providers. The healthcare providers have the feeling that health insurers are only interested in cutting costs and not necessarily the quality of healthcare, by not covering certain treatments which are proven to be effective, which results in that healthcare providers cannot help the patients like they use to do. This frustrates the healthcare providers, because their loyalty lies with the patient and not with the health insurer.

Healthcare providers could also be annoyed by the burden of protocols, which they believe are partly unrelated to the healthcare they need to provide (Hyman, 2001). In the results it becomes clear that the healthcare providers share a believe that declarations are not the number one priority, but it is only “extra work that needs to be done”. They complain about the administrative pressure.

What are the current norms for the declaration process and what kind of errors form the mismatch?

The healthcare providers declare the costs of the provided treatments in complex electronic declaration systems of the health insurers in either codes for healthcare products, or in a Diagnosis Treatment Combination (DBC’s) (Nederlandse Zorgautoriteit, 2017). The healthcare providers who use healthcare product codes, which are in this thesis the dentists, general practitioners and the psychologist, have less problems with making the declarations. Still there are errors that occur in certain situations. Some healthcare product codes cannot be made in combination, which forces the healthcare providers to think of creative solutions to get their payment. Another error occurs from obligated declaration norms which forms a mismatch with the work practice. For example, the norm that it is not allowed to make two declarations per patient per day. Or the norm that different healthcare providers cannot declare the same treatment of the same patient. There are situations in work practice that healthcare providers do have two appointments a day with one patient, or that two healthcare

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providers help the same patient at the same time. In these scenarios the healthcare providers cannot be fully rewarded for the work they have done.

The medical specialists declare the treatments in DBC’s. The DBC- declaration structure has very complex and extensive regulations and there are over five thousand codes, which all have their own specifications (Nederlandse Zorgautoriteit, 2016). Not every possible diagnosis has a DBC-code, and for this reason the medical specialists have to be creative in finding a suiting DBC for the diagnosis that is made. This causes a lot of

administrative pressure what mismatches the work practice. The declaration process is not a priority for medical specialists, and for this reason errors occur like declarations that are not being made at all.

The “grouper”, which is the system that approves declarations automatically before they go to the health insurer, also creates errors. The healthcare providers complain about the extra work that is created by the grouper, which sends declarations back with every little mistake. This causes frustrations among the healthcare providers.

How do healthcare providers normalise or get socialized in a certain declaration behaviour?

Every healthcare provider mentions that they use their social network (mostly colleagues) to discuss the declarations process. They ask each other for help and share ideas and techniques of how they do their declarations. Empirical studies show that rule breaking is socially controlled, because of a high level of agreement about when a rule may be violated (Verkuyten, 1994; Morrison, 2006). The shared believe of the network of the healthcare providers may normalise a certain declaration behaviour. The healthcare providers share the believe that health insurers have other interests than improving the quality of healthcare and that the declaration norms do not work in work practice by errors that occur in the system. The dysfunctional norms for the declaration process makes the rules irrelevant and this is why every healthcare provider is creative with certain declarations. Some of them acknowledge the creative solutions as fraud. Others legitimize their behaviour by saying it is not fraud, but a different way to get their money.

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Which social practices normalise the declaration behaviour of healthcare providers in the Dutch healthcare toward insurance fraud?

The social practices that normalise the declaration behaviour of healthcare providers towards fraud are:

Conflicting social norms and meanings between healthcare providers and health insurers. The healthcare providers are loyal to the patients and this comes in conflict with the obligated norm of health insurers to be more cost conscious. There is also a social norm conflict about the definition of fraud. Health insurers define fraud as criminal behaviour, while healthcare providers see the behaviour as necessary to provide a good quality of healthcare.

Bureaucratic rigidity which results in dysfunctional declaration norms and errors in the declarations system. The declaration process is not a priority for healthcare providers. Errors occur during the declaration process which stimulates the healthcare providers to think of creative solutions. The healthcare providers do not want to put much work in the declarations and for this reason they think of creative solutions, which health insurers define as fraud. Or they do not make a declaration at all.

Shared beliefs in the social network of healthcare providers normalises a certain declaration behaviour. Healthcare providers share the same beliefs about health insurers and bureaucratic rigidity, and this creates an agreement among them that certain rules may be violated.

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28 References

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30 Appendices

1: Incorrect healthcare declarations in The Netherlands, 2016

Source: (Zorgverzekeraars Nederland, 2017).

2: Parties who commited healthcare insurance fraud in The Netherlands, 2016

Source: (Zorgverzekeraars Nederland, 2017).

76% 17% 5% 1% 1%

Fraud investigation 2016

Fraud 76%

Fraud not proven 17%

Administrative error of the healthcare provider, but no fraud 5%

No fraud, but an inaccuracy other than an administrative error 1%

Administrative error of the health insurer 1%

37%

31% 28%

4%

Parties who commited fraud 2016

Healthcare providers 37%

Third parties, such as non-professional healthcare providers and suppliers of tools 31%

Insured persons / budget holders 28%

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3: Interview questions

Interview Questions