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The Board of Healthcare Funders (BHF) has said at least 10% to 15% of all medical aid claims are fraudulent, abusive or wasteful in nature, a substantial expense in a R150 billion industry. The total fraud costs in the South African private health-care system is estimated at approximately R22bn each year.

It is a pity that instead of dealing with this monster in our midst, this national pandemic of looting, much of it deeply systemic, some medical practitioners have resorted to diverting attention away from fraud, waste and abuse.

Judging by the headlines “‘Bully’ medical aids irk doctors” (Business Report, Pretoria News, January 28), “Doctors accuse Medscheme of bullying tactics” (Business Report, The Star, January 28), and “Medscheme cited for unfair practices,”(Business Report, Daily News, January 28), it may seem that it is actually the medical aid companies who are at fault. The story by Sne Masuku, carried by Business Report in the three newspapers, was heavy on conjecture and an unfair misrepresentation of the facts. 

Over the past three years, Medscheme has recovered more than R741.9 million from fraud, waste and abuse cases. There has never been any evidence that doctors are being victimised. However, the recovery of R741.9m and the R22bn total costs of fraud a year is proof that it is in fact medical schemes which have suffered financially as a result of fraudulent claims.

Had Sne cared to contact Medscheme, or editors insisted on balanced reporting, we would have alerted them to the following facts:

The National Health Care Professionals Association brought an application in the High Court against Medscheme and other health-care providers requesting that our forensic processes be declared unlawful and unconstitutional;

The case was dismissed. They were further denied leave to appeal. The court said they had no reasonable prospects of success;

The losing applicants, including Donald Gumede, one of the sources of the story, now face personal costs for reckless litigation. Judge for yourself why he is spreading lies;

Jimmy Mufamadi is not a medical doctor, he is an occupational therapist who misrepresents himself as a doctor and he was paid more than R20m over two years by the medical schemes in the industry for submitting false claims for appliances and services that were never rendered. As soon as a police investigation has been finalised, Medscheme will formalise a case of fraud against him. It is anyone’s guess why he is spreading lies.

Due to the urgent and immediate health-care needs of our clients, payments are paid on the basis of trust and goodwill. So unlike other insurance sectors, where an assessor will first assess a claim to determine validity, we have to pay first and only check validity of a claim afterwards. This naturally exposes the medical aid industry to a greater degree of abuse.

Medscheme will continue to collaborate with health-care professionals, regulators, industry bodies and all stakeholders to reduce fraud, provide sustainable health care and reduce the costs of services.

Anthony Pederson

Chief executive Medscheme