Medical aid providers clamp down on fraud


Cape Town – Medical aid providers are clamping down on fraud, waste and abuse of funds which is costing them millions.

According to a statement issued by Medscheme CEO Anthony Pedersen, the medical aid provider in 2017 recovered R107m which had been lost to fraudulent claims, waste and abuse.

“We received more than 1 500 calls from whistleblowers, alerting of fraud, waste or abuse of medical aid funds,” he said.

Referring to statistics from the Board of Healthcare Funders of Southern Africa (BHF), about 10% to 15% of all medical claims were fraudulent, abusive or wasteful. This added R22bn in expenses to the R150bn private healthcare industry.

Phantom patients

Some of the fraudulent claims include doctors billing for tests they had not performed, or for patients they had not seen. “Once, he (the doctor) billed for seeing more than 80 patients in a single day; some of them were dead. And then there was the patient he said he saw at two different hospitals - on the same day,” said Pedersen.

“Another doctor billed R4m for hearing aids. Depending on the cost of one hearing aid, this may translate to seeing more than 20 000 patients.

“A dentist claimed for teeth that had long been extracted, took unnecessary X-rays and even performed root canal treatment on non-existing teeth.”

Pedersen referred to another example from the BHF, where a physiotherapist billed for 93 appointments in one day. Another doctor billed a scheme for 107 two-hour appointments on a single day, which meant he worked for 214 hours.

Other examples include an audiologist charging R25 000 for a hearing aid bought from China, which cost only R750.

In other cases untrained and unqualified members of the public pretended to be doctors, dispensing stolen medicine, according to Pedersen.

Pedersen said fraud is prevalent in both government and private medical aid programmes, and is becoming more organised.

He explained that medical aid providers have been investing in improved technology to detect fraud, waste and abuse of funds.

“Through software programmes which are able to analyse claims, whistleblower hotline tip-offs and others, we are making progress in curbing the fraud,” he said.

New technology systems designed to stop fraudulent medical aid payments before they are paid has saved the industry billions, he said.

Escalating healthcare costs

“Cutting down on fraud, waste, and abuse is critical to cutting healthcare costs. After all, any funds lost to fraud, waste, or abuse represents money not available to provide care to others, and ultimately increases healthcare costs for everyone,” he said.

Pedersen added that the consequences of medical aid fraud include higher health insurance costs. “Fraud can also cause people to lose access to care, suffer inappropriate or low quality care, lose benefits, and receive unnecessary or incorrect drugs or other things they do not need - all affecting their health and well-being.”

Kenneth Marion, chief operations officer of Bonitas Medical Fund, shares views that fraud, waste and abuse of funds contribute to the escalating cost of healthcare.

Using an analytical software programme, Bonitas detected a R129.8m increase in fraudulent claims, wastage and abuse in 2017, compared to R79m detected in 2016. A total of R38m was recovered, R3m was attributed to fraudulent claims and R35m attributed to waste and abuse.

Bonitas reported 35 cases of fraudulent claims submitted by healthcare providers to the South African Police Service, and criminal cases were subsequently instituted. “Five cases were finalised and all five healthcare providers were found guilty of fraud,” said Marion.

Among the other consequences for healthcare providers include being reported to the relevant medical regulatory bodies, taking civil action against perpetrators and termination of memberships where necessary.

“We will continue to build on criminal successes we have realised in 2017 and take further strides to conquer fraud, waste and abuse,” said Marion.

Steps for members

Marion added that members of medical schemes also have a role to play in combating fraud, waste and abuse.

He advised that they keep their membership details, including their membership number, in a safe place. “Check your medical aid statements to make sure that all claims are correct and for services you actually received,” he said.

He advised consumers to report any suspected wrongdoing to their medical aid scheme.

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