B-Living Issue 2 May 2022 May 2022 | Page 21

A more practical example is of a sheep farmer , who also happens to own an independent pharmacy and claims for sheep sales , from the customer ’ s medical aid scheme . There ’ s also the case of a married woman who used her family medical aid benefits to get her brother admitted into hospital – posing as her husband . The fraud was only detected upon his death .

Common fraudulent provider practices include charging for services never performed , called ‘ phantom billing ’ and misrepresenting services – such as performing a tummy tuck and billing it as a hernia operation or an appendectomy .

There is also ‘ upcoding ’: Billing for a more expensive service or procedure than the one provided and / or paying a patient cash or giving them food or cigarettes to ‘ operate ' on them and then billing the medical aid for the procedure .

Fraudulent activities can create hardships for beneficiaries in many ways . It can distort a patient ’ s medical history when false records are created to support false claims . Like the husband who did not know his wife has used her brother as a beneficiary . This meant his medical aid records reflected that he had already received certain services when someone else had .

In addition , FWA can cause people to lose access to care , suffer inappropriate or low-quality care , lose benefits and , more worrying , receive the incorrect medication or procedures they don ’ t need - all affecting their health and well-being .

Medical aid fraud may also impact a company ’ s reputation , whether it is a fraud that the company committed or the company is a victim . In some cases , employees question whether they are working for an ethical organisation and this affects employee morale , turnover and retention . Not to mention consumer trust .

Is the future grim ? Not completely . Fortunately , we are seeing a renewed commitment to fighting FWA . Through software programmes which can analyse claims , whistle-blower hotline tipoffs and vigilant medical aid members , we are starting to make progress in curbing fraud .

It is time we take a stand against corruption – in any form . We are encouraged by patients , healthcare providers and beneficiaries reporting suspicious charges on their statements . We need to send a strong message to the perpetrators that healthcare FWA will not be tolerated and those found guilty will be dealt with .

Let ’ s all embrace accountability , responsibility , integrity , honesty , fairness , transparency and openness to eliminate fraud , waste and abuse of healthcare benefits .

In another case a patient needed a wheelchair but , due to a previous fraudulent claim submitted and processed , this was denied .

The knock-on effect of healthcare fraud is far reaching . It steals from the business directly resulting in increased healthcare costs , increased monthly medical aid contributions and can negatively impact the bottom line in the same way other forms of theft do .

' Healthcare fraud , waste and abuse – in all its forms - is prevalent in both the public and private healthcare industries and , the sad reality is that it is becoming more organised .'

Bonitas Member Magazine Issue 2 | 2022

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