Fraud,
Waste
and Abuse
– ubiquitous in South Africa
Every day there are hearings around corruption, racketeering and money laundering, again
highlighting the issue of fraud, waste and abuse in South Africa.
What’s not newly exposed though, is corruption in
the healthcare industry. In 2018, the Fund recovered
R31.2 million and had three criminal convictions of
healthcare practitioners for fraud and contravention of
Section 66 of the Medical Schemes Act. The convicted
practitioners were a clinical psychologist, audiologist
and a general practitioner. The good news
Sentences for the cases ranged from 3 to 5 years
imprisonment, suspended for 5 years. The court ordered
them to pay back the quantified amount, combined with
correctional supervision and community service. The impact of fraud, waste and abuse
For the same period, Bonitas obtained convictions with
the Health Professional Council of South Africa (HPCSA),
where two healthcare practitioners were struck off
the register, based on the reported cases of fraud. The
practitioners were a clinical psychologist and a registered
counsellor.
'About R10 billion is lost to fraud, waste and abuse (FWA)
in the healthcare industry annually – which amounts to
about 15% of claims being fraudulent," Kenneth Marion,
Chief Operations Officer of Bonitas Medical Fund says.
"This money could be used to add value and increase
benefits to our members'.
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The Fund has observed a decrease in quantified amounts
of fraud, waste and abuse for quarter four of 2018. The
decrease can be attributed to the analytical tool that
identifies the outliers, as well as sanctions that are
applied by the Fund against healthcare practitioners who
are involved in irregular claiming patterns.
‘The repercussions of fraud are widespread and it has a
direct impact on every member of the Fund,’ says Marion.
‘Medical schemes are not-for-profit and are in fact owned
by their members. So when the Scheme is defrauded,
it impacts funds to pay for claims and can contribute
towards increased premiums.
What is 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 offence which
carries a fine, imprisonment or both.