MedCo – Getting its act together

There is no question that MedCo got off to a shaky start.

Since it was brought into being in 2014, it has been largely dismissed as ineffective in the struggle against fraud.

But it is tackling those problems and aims to come out fighting, according to MedCo director Susan Brown (pictured right).

Initially, MedCo was hamstrung by its own structures.

“It went horribly wrong,” Brown admits.

It wasn’t helped by the fact that all its data was input by the same Medical Reporting Organisations (MROs) that it was set up to scrutinise. That meant that MROs at the sketchier end of the market could choose what data to enter, and that allowed them to game the system.

With MROs appointed to claimants on the basis of postcode, MROs claiming to operate at a large number of addresses could garner a large number of referrals. The records also show some doctors scheduling an inhumanly large number of appointments in a single day.

Incomplete and inaccurate data, and an inability to sanction offenders rendered MedCo largely irrelevant.

“There were mistakes setting up MedCo,” Brown says.

“There was a very short timetable; all the MROs were allowed to register on the system without doing any checks at all, and they were self-certifying as to how big they were and if they had national coverage.

“That was a huge mistake, because instead of being the gatekeeper when letting them on the system, we’ve had to audit them after the event.”

But all that is changing, Brown asserts. Against opposition from some MROs, last year the qualifying criteria for MROs registering with MedCo were tightened up, and MedCo has completed an audit of its Tier 1 companies.

“We’re taking action to address mismatches between what the organisations told us they were doing and what they are actually observed to be doing,” she says.

“It’s meant that MedCo has taken all this time to get down to what we really wanted to be doing in the first place, which is to look at the expert behaviour and try and tackle it from that end: the experts who are doing poor quality reports, the experts who are not even seeing the claimants, certainly not examining them properly.

“And because of the access to data that MedCo has, we can see links between experts and rehab providers, links between experts, law firms, and claims management companies. We do have a lot of information that we’re starting to use to address the behaviours that we can see.”

Brown says MedCo has started to explore working with the Insurance Fraud Bureau and the Claims Management Regulator “So we can move forward in a more informed way.”

Simon Margolis, chairman of medical examinations group Premex and chair of MedCo’s expert audit and peer review subgroup (pictured left), agrees MedCo has turned a corner, but he admits there is still some way to go.

“We are finally getting to where we wanted to be four years ago,” he says.

And he holds up the prospect of MedCo disciplining MROs that step out of line.

“How do you name and shame? We’re close to doing that now,” he says.

“At some point we will be taking action against a number of experts. And as a consequence of that, I’m reasonably hopeful there will be other experts, who are maybe doing things that they shouldn’t be doing, who will look at that and say to themselves: ‘Hang on, maybe I need to start thinking about that.’

“They will then know that we are gathering data, and we are now acting as the focal point for industry complaints.”

Margolis cautions that, in taking action against transgressive MROs, evidence has to be “robust”.

“Where we’re going to win is where we can tie in information with other people,” such as insurers, the IFB and the Ministry of Justice’s Claims Portal, he says.

“At the moment it’s the experts or the MROs that upload the data on MedCo. It’s not happening 100% of the time, and we have no way of knowing if what they’re uploading is accurate.

“We need in future to tie up information between MedCo and Portal Co so that, if it’s on Portal Co as a claim, and if the expert hasn’t uploaded the data on MedCo, then the insurer can turn around and say: ‘I’m not settling the case because there’s no data.”

Sanctions that can be used against MROs include compulsory retraining for accreditation, suspension or complete deregistration from MedCo.

Have the early problems been addressed?

“It’s going to be an ongoing process,” says Brown. “Every time we identify one form of behaviour and put a stop to that, another one pops up. It’s the whack-a-mole effect. At every level we think we’ve addressed everything, and then we see behaviours that are outside anything we had ever dreamt of.”