Bonitas Member Magazine B-Living - Issue 2 | Page 29
How does it aff ect you?
Fraud, waste and abuse have a direct impact on healthcare
inlation and contribution increases. As medical schemes
are owned by their members, it has an indirect impact on
each and every member.
Last year, we introduced advanced analytical
software to help us detect fraud
Known as Insurance Fraud Management Software,
this sophisticated analytical program enables us to
identify irregularities in all claims received that could
be indicative of fraud, waste and abuse. We have also
intensifi ed our eff orts to combat fraud, waste and abuse
along with our dedicated service providers.
However, the most invaluable tool agains t fraud,
waste and abuse, remains our valued members.
You can use our toll-free fraud hotline to report
any incidents of suspected fraud, waste and abuse.
Simply call 0800 112 811.
What is the penance for medical aid fraud?
According to Section 66 of the Medical Schemes Act,
medical aid fraud, committed either by a member or
a healthcare practitioner, is a criminal off ence which
carries a fi ne or imprisonment or both.
In the case of healthcare providers, it depends on each
and every judgement as well as the fi ndings of the Health
Professions Council of South Africa (HPCSA) in terms of
what punitive measures are to be imposed and each case
is therefore adjudicated on its own merits. Fraud, waste
and abuse are categorised together, but in the event of
fraud, it is harder to convict because of the burden of
proof that rests with the victim in terms of the Criminal
Prosecution and Procedure Act.
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Tips to prevent fraud
» Keep your personal medical scheme
details (such as your membership number)
private
» Check your medical scheme statements to
make sure that all claims are correct and
that you actually received the services
» Make sure the services delivered to you are
the same as the claims submitted on your
statement
» Keep your membership card safe
» Avoid any activities whereby you receive
cash back for providing your membership
details or other benefi ts that are not
in line with the stated benefi ts on your
option
» Do not hesitate to query any irregularities
relating to your claims with the call centre
» Report any suspicion of fraud to our Fraud
Hotline on 0800 112 811 – you may
remain anonymous
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