Recovering cost of medical aid fraud

Abuse of your medical aid ends up hurting you in the pocket, even though it may seem like a victim-less crime.
Abuse of your medical aid ends up hurting you in the pocket, even though it may seem like a victim-less crime.
Image: 123RF

More than 8.8 million South Africans brace themselves for the rising annual cost of medical scheme cover to ensure their families receive quality healthcare services should the need arise.

However, it is not just consumer price inflation that sees you forking out more for your health plan each year but also the rise in medical aid fraud.

"Up to 25% of the money you pay for your medical aid is lost to fraud, waste and abuse, costing the private healthcare sector between R22-billion and R28-billion every year," explains Dr Katlego Mothudi, managing director at the Board of Healthcare Funders.

What is medical aid fraud?

According to the Council for Medical Schemes, medical aid fraud refers to an intentional deception or false statement of facts in a claim that could result in a benefit or payment that would otherwise not get authorised, including:

• Non-disclosure of pre-existing conditions by the member to the scheme;

• Allowing your healthcare provider to charge for services not provided;

• Loaning your medical scheme card to unregistered dependents, including family and friends;

• Providing your medical scheme or policy details to a healthcare provider to submit a false claim for a financial kickback;

• Buying non-medical goods with your medical aid card from doctors and/or pharmacies; and

• Being admitted to hospital for a non-existent ailment to benefit from the cashback payment from your insurer.

Other examples include claiming for fillings when cosmetic dental work was done, ordering unnecessary blood tests or even obtaining sunglasses where a claim for prescription spectacles have been processed.

A major criticism faced by medical schemes in SA is that they do not communicate effectively and enough with their members regarding the issue of fraud and when a member could potentially be committing an offence.

It is therefore important that all stakeholders understand what constitutes inappropriate behaviour as well as the consequences that may result from such conduct.

"Look, we understand that communication from a medical scheme to a member is usually thrown in the trash unless it contains a cheque, but more effort needs to be made to ensure that consumers remain informed and educated at all times to make quality healthcare more accessible to more South Africans," says Paul Midlane, general manager of healthcare forensics at Medscheme.

Dr Simon Mangcwatywa, principal officer at Sizwe Medical Fund says the best way to keep members informed is for the medical scheme to constantly share content with its members. Education places power back in the hands of members and gives them the incentive to use their medical aid card responsibly and play their role in reducing the cost of medical aid fraud by:

• Seeking second opinions before any procedures;

• Questioning any and everything to pick up unlawful acts by service provides;

• Seeing a GP before a specialist to ensure the right referral is given;

• Investing in preventative care and exploring non-invasive options where possible; and

• Viewing medical aid cover as a necessity that gives access to quality care as opposed to a grudge purchase.

Imagine for a moment a world with no medical aid, where you would have to pay for all medical and associated costs from your pocket.

Most people would not be able to afford it, so inevitably if the cost of care dropped, it would be to the benefit of all South Africans, whether they're on medical aid or not.

Industry experts who recently met at the Sandton Convention Centre for the Council of Medical Schemes' Fraud, Waste and Abuse Summit agree that though medical aid fraud is a complex form of financial fraud that is often hard to detect, monitor and prevent, industry collaboration and members blowing the whistle on detected fraud can go a long way in diverting the loss from where it hurts the most - your pocket.

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