Bonitas Member Magazine B-Living - Issue 2

Real examples of healthcare fraud Psychologist billing for extra hours A psychologist was investigated after his claims were analysed. It was found that he was claiming for services, rendered to Bonitas members, for durations of up to 57 hours per day, which is impossible. The psychologist was operating a sole practice and did not employ any additional psychologists, and services and claims are hour related. After an investigation was conducted, we established that the psychologist submitted false claims and used the following methodology: • Claiming for services not rendered • Found that in some instances the psychologist was not known by the members and that he obtained their details fraudulently • Longer hourly sessions were claimed • Some members consulted once but the psychologist submitted claims on a monthly basis A criminal matter was lodged and the psychologist was prosecuted for fraud. Pharmacies approving claims for non-medicinal items Information was received that several pharmacies, in a specific area, were supplying members with cash, toiletries and groceries. The pharmacist then submitted false claims to cover the costs for the non-claimable articles. Upon further investigation, we found that the pharmacists of six pharmacies operated in conjunction with several GPs to carry out the scheme. The following modus operandi was uncovered: • The members receive non-claimable articles such as toiletries, cash and groceries • The pharmacist submits false claims for high-cost medication to cover his expenses • The pharmacist obtains a false prescription from participating GPs to cover for claims submitted for scheduled medication • The GP then also submits false claims for consultations without consulting with the members A full-scale investigation in conjunction with the SAPS was lodged and an undercover operation was conducted by the SAPS. Pharmacists from six pharmacies and several GPs were arrested and prosecuted successfully for fraud. Other examples include: • Practitioners using the wrong ICD-10 codes • Charging co-payments that are incorrect • Ordering procedures and tests which are not medically necessary • Claiming for extra consultations and hours • Allowing other people to use your medical aid card Healthcare fraud is a very serious offence. Members involved in fraud risk having their membership cancelled. They could also face criminal prosecution that may also affect their employment, as employers usually subsidise medical aid contributions. Join the fight against fraud The greater the losses through fraud, the higher your contributions are to help cover this loss. You can help to combat fraud by anonymously contacting our fraud hotline on 0800 112 811 if you are aware of any practitioner or patient abusing the system. Page 29 B-Living Issue 2, 2017

Bonitas Member Magazine B-Living - Issue 2 | Page 30