Doctors and members of medical aid schemes warned to stop defrauding schemes of billions
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DURBAN - The Board of Healthcare Funders (BHF) estimated an annual R22-billion loss in medical scheme funds from fraud and abuse of medical aid scheme membership.
Dr Hleli Nhlapo, chairperson of the BHF’s Healthcare Forensic Management Unit (HFMU), said members still failed to understand that stealing from their scheme meant that they were stealing from themselves.
Nhlapo said, in KwaZulu-Natal, in addition to claims for non-medical related expenses, members used medical aid funds for the purchase of expensive pots and designer sunglasses. He said a pattern of new trends was emerging during the pandemic, making it all the more concerning for the body.
“Over the past 18-months, we have seen new patterns of fraud and abuse emerging in healthcare. It is not individual providers anymore, for example, just one pharmacy committing fraud, but now it is syndicates – it’s organised crime,” said Nhlapo.
He cautioned members to remember that medical aid schemes worked on community rating.
“In KZN, Durban central and surrounding townships, we have seen a continued pattern of people going into doctors rooms, and after the fake consultation, they split the funds at 30% for the healthcare provider and 70% for the member. When you go further north of Durban, it's a 35% to 75% between the healthcare provider and the member,” said Nhlapo.
The HFMU discovered that audiologists rose in the reported fraud case charts, starting pre-Covid-19.
It said partly due to provider claims for expensive hearing aids, which were charged at up to five times more than the cost of actual devices that patients were being given or where claims were wholly fictitious.
He said during the pre-Covid-19 period, from January 2018 to March 2020, general practitioners, pharmacies and psychologists topped the list, only to be overtaken during Covid-19 (April 2020 to June 2021) by the discipline of Speech therapy and Audiology, with dieticians not far behind.
“There are a lot of people in KZN with sudden hearing aids, and what is worse is that they are not even the ones that were claimed for, but an inferior one.”
Nhlapo said medical scheme members had become as sophisticated, even claiming for car spare parts with their medical aid schemes funds. “Medical scheme funds remain a grudge purchase, and we know that most people engage in this activity because they feel if they are not going to get the money back, they must find other ways to access the funds. They feel entitled to the money.
“What is very concerning and why we are asking members to stop is because schemes increase member contributions each year based on the 90% healthcare expenditure and 10% on administration costs.
“Most of these claims later are found to be fraudulent. Members are stealing from themselves, and they need to stop and understand the implications. We strongly advise cash-strapped members to stop going into hospitals so they can claim from their scheme because they are taking up space for someone who could have a serious illness, and later, they are compromising themselves from accessing the best healthcare available, which is what they are paying for,” said Nhlapo.
He added that another whistle-blowing for the HFMU was also ironically from soured relations between the syndicates themselves.