Medical aid fraud decreases

2012-01-10 12:58

The number of fraud cases in the medical aid industry has decreased, according to a survey by KPMG.

The Medical Schemes’ Anti-Fraud Survey, which covered the three years from 2007 to 2009, showed that the fraud-to-claims ratio had fallen by 0.15%, said national forensic director for healthcare Camilla Singh.

“We can clearly see the ratio of investigated fraud to claims is dropping. This is an achievement for South Africa’s medical aid administrators,” said Singh.

The survey was sent to 15 administrators and the eight respondents represented 84% of all principal members.

Medical schemes which participated in the survey included Discovery, Medscheme, Metropolitan and Momentum, said Singh.

She said the survey showed that the number of fraudulent claims by members was also at a low.

This amounted to R67.3 million out of a claim value of R145 billion over the three-year period.

The most common reason given for member fraud was non-disclosure of prior ailments. This amounted to about 92% of all cases, said Singh.

However, service provider fraud was increasing. Code manipulation was the most common type investigated, followed by services not rendered, Singh said.

“There has been a definite crackdown on fraud in this industry in the last decade.”

In KPMG’s 2001 to 2003 survey, only 49% of medical aid administrators said they never kept quiet about fraud cases, said Singh.

By 2009, this had risen to 100%.


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