Know your doctor

Following the Government’s response in October to the consultation on reducing the number and costs of whiplash claims, there has been an increased focus on medical experts within the industry. A key outcome of the consultation which merits further consideration from the fraud arena is that of the proposals to better manage medical experts who deal with whiplash claims.

This is a particular area of focus within Keoghs’ counter-fraud services (CFS) division, with Simon Winnard, Director of Healthcare Fraud, leading a review of the main medical experts used across claims received by Keoghs. Simon commented: “Whilst the need to regulate medico-legal work has been well documented, a closer look at the doctors dominating the marketplace perhaps gives more immediate cause for concern. Keoghs has received medical reports from over 2,500 medical experts on cases we are progressing. Reviewing the top 20 (by volume of cases) you would reasonably expect they should account for 1-3% of cases, however the reality is that they account for almost 20% which immediately starts the alarm bells ringing.”

Taking a closer look at the top 20 medical practitioners, the review revealed that:

• Five have current restrictions on their medical practice
• Seven do not hold NHS posts and are not on the General Medical Council (GMC) GP or Specialist register
• Two are only allowed to see female patients with a chaperone
• One has recently been convicted of theft and received a custodial sentence
• One doctor can only work on medico-legal and has to be supervised when doing so (he also has a four year driving ban following two convictions)
• Another has a warning on her medico-legal work in relation to DPA compliance and the use of a third party

Keoghs’ new healthcare fraud capability is allowing us to look at this area in more detail for the first time and assist clients in identifying the risks to their business. As such, over the past few weeks we have produced our first intelligence reports on specific doctors. We have also started to receive instructions to investigate doctors in more detail and are also collaborating with law enforcement and the GMC. Early examples of cases we have worked on include where the doctor:

• is claiming to have examined a patient who was actually in prison at the time of the accident and examination
• appears to have had his identity used to produce fake reports
• claimed to have examined a male patient when the claimant was female

As part of our investigations we are also focussing on the financial and other links between doctors and accident management companies, medical agencies, physiotherapy companies and the referral patterns between them.

Having investigated doctors for a number of years, Simon is far from surprised by what he has seen but nevertheless encouraged at the opportunity for Keoghs to lead the way in this area. He concludes: “There has been a great deal of initial interest shown in this work and we are delighted to be able to offer detailed reviews and investigations into doctors providing medico-legal assessments. Given the lack of regulation in this area we suspect that our findings to date are merely the tip of the iceberg. We therefore look forward to using our healthcare experience and expertise to help our clients tackle the issue and also to leading the way in driving changes to this dysfunctional part of the claims process.“