Being vigilant
Our most invaluable tool against fraud, waste and
abuse (FWA) remains our members. To assist them to
be proactive in joining us in the fight, we have a toll-
free fraud hotline 0800 112 811 to report any incidents
of suspected fraud, waste and abuse and we encourage
them to use it.
In our experience, the biggest single deterrent is
making it known that we are actively investigating
every suspicious or unusual claim or activity and to
also report convictions. Education goes a long way in
curbing the abuse of medical aid benefits in terms of the
relationships between medical aids, healthcare providers
and members.
The upside is that our fight against FWA is
showing good returns.
• There have been 7 convictions of healthcare
practitioners
• 28 ongoing criminal cases involving false claims
• 54 active cases reported to the Health Professional
Council of South Africa (HPCSA)
• 762 hotline reports on FWA
• R297 million quantified in fraud since 2016
• R84 million recovered to date, R43.3 million of that
during 2018
• Total savings to date of R174 million realised
The stats:
Around 15% of claims in the healthcare industry contain
an element of FWA. During 2018, FWA amounted to
R106.2 million and was made up as follows:
• Facilities – R16.5 million
• Pharmacies – R15.7 million
• Medical professionals – R74 million
Trends in Fraud, Waste and Abuse:
Lack of practice number vetting
Practitioners under investigation apply for multiple
practice numbers in order to circumvent sanctions. The
Board of Healthcare Funders (BHF) is aware of the concern
the Fund and the industry have around multiple practice
numbers. To crack down on this fraudulent activity, the
Fund introduced a vetting process, in co-operation with
the administrator, to screen all new practice numbers. Appliances mark-ups
We see mark-ups of up to 300% being added to poor
quality devices that are supplied by the treating
practitioners.
HPCSA sanctioning
Practitioners reported to HPCSA for fraudulent
behaviour, are not being sanctioned sufficiently to be a
realistic deterrent. Engagement with HPCSA by the Fund
is ongoing with the hope of highlighting the effects of
fraud not only to Bonitas but the healthcare industry. Syndicate-related fraud
Runners supplying member details to various healthcare
practitioners, who in turn submit claims for services
allegedly rendered with or without the members'
knowledge.
Pharmacy Council sanctioning
The Council is reluctant to take action against fraudulent
pharmacies unless a criminal conviction has been
obtained. This poses a risk as the legal process can be
lengthy before a case is finalised. A runner in this context is someone who the healthcare
practitioner is working with, to tout more people in joining
the illegal activity. One runner has just been dismissed
by his employer as a result of his part in defrauding the
Fund. His criminal case was withdrawn by the state after
the doctor he colluded with admitted guilt.
Emergency services
We have identified a trend where emergency service
vehicles are used for general transport and claims are
submitted as though members had an emergency.
Falsified invoices
Healthcare practitioners submit falsified invoices for the
devices they allege to have dispensed to members.
Rehabilitation centres/Wellness centres
An example of this is when members are admitted and
other service providers consult with them without the
knowledge of the treating doctor.
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