Bonitas Member Magazine B-Living - Issue 2 | Page 28
Making sense
of medical aid
fraud, waste &
abuse
Fraud, waste and abuse in the healthcare
industry is one of the main drivers of healthcare
inflation and increases in claims costs. But what
is medical aid fraud and how can it be stopped?
Claims that are submitted to medical schemes for
services that are not rendered or medically necessary
is fraud. This has a direct and negative impact on the
members. All payments made in relation to fraud
result in higher contribution increases each year.
These increases, together with the normal escalating
costs associated with healthcare, result in our members
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being made acutely aware of the impact of these
increases as they are usually higher than inlation and
aff ect us all.
What is medical aid fraud?
When a member, administrator or healthcare provider is
dishonest in order to get money to which they are not
entitled. Medical aid fraud is the most complex form of
fi nancial fraud to detect, monitor and prevent.
Who can commit fraud?
Anyone who has access to medical aid information, from
members to healthcare providers and receptionists
in doctors’ rooms, can commit healthcare fraud.
Unfortunately, unscrupulous healthcare practitioners
are the main culprits. The Hippocratic Oath may not
specify that medical aid fraud is a criminal off ence but
it is understood to incorporate a standard of ethics to
which all medical practitioners should adhere. The good
news is most of them do. It is the few bad apples that
are involved in corruption and are costing medical aid
schemes billions of rands each year. Not to mention
letting down the good reputation of the medical
fraternity in the eyes of the public. That said, the culprits
are all along the healthcare delivery chain including
employees and medical scheme members.
B-Living Issue 2, 2017