Bonitas Member Magazine 2018 - B-Living Issue 1 | Page 18

Fighting fraud, waste and abuse Fraud, waste and abuse in the healthcare industry is one of the main drivers of healthcare inlation and increased costs. This is a key focus area for Bonitas and we’re pleased to report that we’ve made great strides in the fi ght against fraud, waste and abuse. The private healthcare funding industry spent over R150 billion in 2016. Of this, a staggering 10-15% of claims contained elements of fraudulent information – adding an estimated R22 billion to the annual cost of private healthcare in South Africa. Over the years, Bonitas has observed an increasing trend between abuse of members’ benefi ts by certain medical service providers and the potential for fraudulent claims as a result of collusion between medical service providers and, in some instances, members of the Fund. This behaviour undermines the fi nancial sustainability of the Fund. Because a medical scheme is a not-for-profi t organisation that operates solely for the benefi t of its members, healthcare fraud, waste and abuse has a direct impact on the membership base. 2017 showed excellent results To minimise the impact of the above and to some extent address it, Bonitas adopted a zero-tolerance approach to fraud, waste and abuse. During 2017, our activities to detect and clamp down on fraud, waste and abuse Page 17 were amplifi ed, with excellent results. We identifi ed over R129,8 million in fraudulent claims in 2017 compared to R79 million in 2016. Over R38 million was recovered, compared to R19 million in 2016. Savings attributed to behaviour change amounted to R75 million in 2017. Bonitas investigated 35 cases of healthcare providers submitting fraudulent claims These cases were then reported to the South African Police Services and the Specialised Commercial Crime Unit, and criminal cases were subsequently instituted. Five cases were fi nalised and all fi ve healthcare providers were found guilty of fraud. Three of these providers are serving prison sentences of 9-10 years, while one received a suspended sentence. Another provider is awaiting sentencing in February 2018. The remaining 30 criminal cases are at various stages in court. B-Living Issue 1, 2018