The country’s largest manager of medical aid schemes, Medscheme, has recouped more than R107 million claimed fraudulently and through waste or abuse.
The company further recovered more than R300m in reduced claims through forensic interventions.
“Using the company’s robust data analytics system, Medscheme was able to identify claims that fell outside the average patterns. Investigations into these claims confirmed fraud and abuse,” said Anthony Pedersen, chief executive of Medscheme, a subsidiary of Afrocentric Group.
Pedersen urged customers to take an interest in and thoroughly examine their statements, as well as understand what services their medical schemes were being charged for.
“We received more than 1500 calls from whistle-blowers alerting us of potential fraudulent, wasteful or abusive conduct committed against medical aid funds.
"This is important, as ultimately the customer pays for the fraud, waste and abuse or any increasing costs through high annual increases of the premiums,” said Pedersen.
“It is a pity that as long as a medical scheme continues to pay, patients never ask whether the physiotherapist or dietitian at the hospital was actually a necessary expense to incur or if the pharmacist has dispensed the generic (but claimed for the more expensive original), or if your medical scheme also paid for that pathology account you keep getting in the mail,” he said.
Fraud, waste and abuse were defined as intentional deception or misrepresentation that a person knew to be false or did not believe to be true; misreporting data to increase payments; paying kickbacks to providers for referring patients for specific services or to certain entities; or stealing providers’ or patients’ identities.
Medscheme administered both open and closed medical schemes.
The company’s data analytical capabilities enabled it to not only provide strong health administration and managed care, but also to deal with fraud.
The software detected irregular claims and ensured only valid health-care claims were paid to health-care providers and facilities.
With 13 forensic clients and over 1.8million lives on a single analytical platform, Medscheme enjoyed strong insight into the claiming patterns and behaviour of any health-care provider, pharmacy or hospital in the country, Pedersen said.
The Board of Healthcare Funders said it was estimated that at least 10 to 15% of all claims were fraudulent, abusive or wasteful in nature, a substantial expense in a R150billion industry.
Pedersen urged members of medical aid schemes to help ensure that they did not become victims of medical aid fraud, waste and abuse by:
Treating the medical aid number like a credit card. Never give it out over the phone unless you initiated the call. If the card is lost or stolen, report it immediately to the scheme.
Not to accept free medical services or equipment in exchange for a medical aid number. Unscrupulous companies or individuals could use this number to bill for services or products you did not receive.
Review medical aid statements closely and keep a watch for services paid for but never received.
If one suspects fraud, report it immediately.
“Every person who pays for health-care benefits, every business that pays higher insurance costs to cover their employees, and everyone who pays medical aid is a victim."