Fighting fraud, waste
and abuse
Fraud, waste and abuse in the healthcare industry is one of the main drivers of healthcare inlation
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
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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