Automated verification of prescriptions helped crackdown on medical fraud
Portugal’s national health service introduced a centralized, automated system to verify medical prescriptions in 2016. One year later, it flagged 20 million euros of fraud.
Which doctors give more medical prescriptions? Which ones prescribe more expensive medicines? How many doctors have more than 100 packages dispensed from the same pharmacy, on the same day? How many packages are dispensed from each pharmacy when the expiry date is about to end?
These are some of the questions answered by the Control and Monitoring Center from the Portuguese Public National Health Service, Centro de Controlo e Monitorização do Sistema Nacional de Saúde (CCM-SNS), using data from several databases, to detect and fight prescription fraud. The “paperless prescriptions” program and the electronic medical prescription system started in 2016 and were made mandatory for the public sector, although exceptions were allowed in some cases.
Doctors fill in the prescription, using software certified by the Shared Services of the Ministry of Health, Serviços Partilhados do Ministério da Saúde (SPMS), sign it digitally, either with their Portuguese Citizen Card or with their Order of Doctors’ card, and send it to the patient’s mobile phone by text message or email, or print it out. Doctors can also use a mobile app to issue prescriptions, even remotely, by signing them with their Digital Mobile Key. This is a means of authentication created by the Portuguese government that connects a mobile phone number to a Portuguese citizen identification number. Patients can also use their Citizen Card to buy prescribed medicines from a pharmacy.
When the system was announced, back in 2015, the national newspaper, Público, reported that about 15% of the seven million prescriptions written each month were not bought, either because patients could not afford them or because they decided to forego treatment. The new system lets doctors know if the prescriptions were bought or not. Another novelty is that patients can buy the prescribed medicines from different pharmacies, in case one pharmacy does not stock all of them.
One of the major motivations, as well as optimizing resources and reducing costs, for using the electronic prescription system was to control the use and detect fraud.
Fraud was reduced by 80% during the first year of the new system, according to the National Health Service (SNS). In 2019, 97.28% of the prescriptions in the public health sector were electronic (the share of electronic prescriptions is
much lower in the private sector, where the practice is not mandatory). The system allows the SNS control center to quickly monitor and detect irregularities by automatically analyzing patterns in the prescription and dispensation of medicines.
The Control and Monitoring Center uses data from invoices issued by pharmacies and other providers of services, such as medical exams. This data set is complemented by information from electronic or paper prescriptions from the databases of the Ministry of Health, such as the National Prescription Database (Base de Dados Nacional de Prescrições, BDNP); the Vignettes and Prescription Requisition Portal; and the National Medicine Database. The control is made at the prescription phase, where the system verifies that the doctor is registered and can make the prescription and that the patient exists and can benefit from it.
In 2011, RTP, the public sector broadcaster, reported that the police were investigating a case of fraud that happened in 2009 and 2010, before the new system was in place. Prescriptions had been written in the name of deceased doctors, using falsified signatures, or to deceased patients. Several doctors were using the same professional license number and one doctor made 32,000 prescriptions in only one year – one every 3 minutes. The targets were expensive medicines with a high percentage of reimbursement by the SNS. With a drug costing 100 euros and a reimbursement rate of 90%, a pharmacy can get 90 euros from the SNS by presenting a prescription written by a doctor, without having sold the medicine. The news report mentioned that medicines represented 40% of all public expenditure fraud.
Another type of fraud can happen when patients from the public sector are referred to the private sector. In January 2014, SIC, a private TV channel, reported that the private health group Sanfil invoiced ADSE, a public health sub-system, for medicines and medical exams that had not been provided to the referred patients.
The fraud control system also uses the Ministry of Health’s National Registry of Health Users, which contains information about the benefits patients are entitled to (the reimbursement rate varies depending on employment status, with different schemes for pensioners and public-sector employees). This allows for the immediate verification of each transaction to the different health providers. The National Commission for Data Protection authorized the practice.
Back in public hands
The computerization of the system of fraud detection for complementary means of diagnosis and therapy dates back to the 1980s. The system was extended to medicine prescriptions in 2003, under the aegis of the Central Administration of the SNS, with data coming from regional health administrations.
In 2007, the Council of Ministers earmarked over 30 million euros over four years to create and implement the Invoice Control Center (Centro de Conferência de Faturas, CCF), now called Control and Monitoring Center. The project was carried out by a private company, PT Comunicações, from the design to the implementation and operation phases.
Until then, the system to control the invoices involved around 500 workers spread across a variety of offices around the country, leading to high costs for the National Health Service and difficulties in obtaining results in a timely manner. In 2005, there were 23 million prescriptions for complementary means of diagnosis and therapy and 55 million prescriptions for medicine.
At the same time, the Ministry of Health tried to increase the use of electronic prescriptions – from an estimated 40% at the time. The promise of timely and easy fraud detection was a big motivation for the push towards digitization. However, it could only be done if the entire technological ecosystem was updated to deal with it.
The Invoice Control Center (CCM) started operations in 2010. Two years later, the Information Exploration Unit was created to analyze data gathered by the CCM and to detect anomalous and potentially fraudulent situations, to develop a fraud risk analysis model, and to forward suspicious cases to the police.
Over the first seven years, the central unit detected irregularities amounting to hundreds of millions of euros and was instrumental in starting many prosecutions for fraud in the health system. According to the Ministry of Health, in the first semester of 2017, the Invoice Control Center processed prescriptions worth 356.2 million euros and flagged 21.1 million euros to the State prosecutor.
Although the Invoice Control Center was always under the Central Administration of the SNS, the management, maintenance, and operation of the center were provided by a private operator until June 2018. At that time, the Council of Ministers transferred responsibilities for this unit to the Shared Services of the Ministry of Health (SPMS), putting it entirely under the control of the public sector.
The government justified the transition by considering the activity of the center as strategic to the efficiency of the SNS and to the management of public expenditure. Data protection considerations also played a role.
In December 2019, the adjunct Secretary of State for Health, Jamila Madeira, made an official visit to the premises of the Invoice Control Center. She said the center was a priority for the government because “rigor, transparency and permanent monitoring are essential instruments in the fight against fraud and corruption”. Each month, the center checks 8 million documents, 70% of them digital.