Gems worried about fraud and antiselection

Author: Kabelo Khumalo

The Government Employees Medical Scheme (Gems) now provides healthcare cover for almost 57% of eligible public service employees, Gems said in its annual report for 2016, released this week.Gems says it faced numerous challenges last year, including a sharp increase in claims, fraud and anti-selection.

Anti-selection is when beneficiaries join a medical scheme for a short period to claim for expensive medical care and resign once the scheme has paid for their treatment.

Gems says beneficiaries practising anti-selection claimed R149 million from the scheme, while they contributed R30m in 2015.

Gems principal officer Dr Gunvant Goolab says the scheme is taking action.

“Gems uncovered an alleged syndicate that made significant irregular claims for the services of clinical psychologists. We can now report that this was handed over for investigation by the Commercial Crimes Unit of the police in March 2017,” Goolab says. 

Gems plans to manage high claims by introducing advanced claims management and deploying on-site case managers.

With regard to anti-selection, the scheme says it introduced limited underwriting and condition-specific waiting periods from October 2016. One in 10 new members and beneficiaries us now subject to some form of underwriting.

Gems introduced its Emerald Value Option, which rewards members for accessing healthcare through their nominated general practitioner, including referrals to specialists and network hospitals.

Goolab allayed fears about Gems’s financial sustainability, saying its cash position stood at R4.5 billion.

“We are working to an approved business plan with the Council for Medical Schemes to reach an agreed reserve ratio of 8.2% for 2017, and are on track to achieve this target. Our members and the healthcare service providers who care for them can be assured that Gems remains able to fully meet its obligations in order to provide the best possible care for our members.”

Key statistics in Gems’s 2016 financial year:

• Principal members: 694 262
• Percentage of eligible public service employees on Gems: 56.78%
• Beneficiaries: 1 833 137
• Average age of individuals covered by Gems: 31 years
• Average size of a family covered by Gems: 2.64 people
• Pensioner ratio: 14.36%
• Annual gross contributions: R31 043 708 744
• Non-healthcare expenditure: 5.7%
• Reserve ratio: 6.99%
• Disease-screening tests performed: 162 842
• Hospital admissions: 457 026
• Specialist consultations: 1 013 584
• General practitioner consultations: 5 527 404
• Prescriptions dispensed: 44 419 296
• Claims settled: 92.2 million
• Gems has 18 walk-in service centres, 88 self-service kiosks and 3 000 client-liaison sites nationwide

Source: Personal Finance