Healthcare sector fraud on the rise
Medical aid schemes were defrauded to the tune of R10-billion in 2017 alone, the Board of Healthcare Funders said.
The organisation said both professionals in the healthcare sector and members commit the offences. In 2017, R151-billion in medical aid claims was paid out with between five to 15 percent of those being fraudulent.
“We see a lot of collusion between members of schemes and service providers (which) relates to issues like identity fraud – your uncle falls ill and you pass him (off) as you or another member,” said Dr Katlego Mothudi, MD of the Board of Healthcare Funders.
South Africa’s biggest medical aid scheme, Discovery Health, said it was defrauded to the tune of over R500-million in 2017.
The company has identified several scams.
“In the pharmacy environment what we see, for example, is a pharmacist selling to a member cosmetics and other front-shop items but submitting claims for medicine to the medical scheme, or we see a pharmacist dispensing a low-cost generic medicine, but submitting a claim for a higher-cost, original brand medicine.
“In the doctor environment, we see an abuse of codes, the doctors treating and doing one thing but sending in a claim for much more money,” explained the Discovery Health’s CEO Jonathan Broomberg.
The Council for Medical Schemes said forensic audits might become necessary to protect the interests of members, while the Board of Healthcare Funders believe awareness campaigns could help.
Several health professionals and service providers have already been criminally charged or convicted.