Medical aids are expecting a run on scam claims over the next few months as the economic squeeze gets tighter.
The increase in scams by medical aid members - often colluding with medical service providers - could see medical aid fraud soar beyond its already frightening R8-billion a year.
The Board of Healthcare Funders has been concerned for a number of years about the level of fraud, which, in conjunction with spiralling medical inflation, impacts on members in terms of increased premiums and reduced benefits.
Administrators say member-related fraud, where patients collude with healthcare professionals in exchange for money or other "gifts", has become one of the more common types of fraud.
And they believe that, given the economic pressures currently experienced in South Africa, it may increase.
Forensic auditors KPMG have warned that administrators had better tighten controls and develop innovative data analysis technology because, in a recessionary climate, people are under financial pressure and are more likely to commit fraud.
Dennis Mayaba, senior manager of the special investigations department at Medscheme, says that while fraud involving healthcare professionals was more common three to four years ago, member-related deception has recently overtaken it.
"Before, practitioners would overcharge on claims - claiming for up to three times more than they informed their clients. People wouldn't really know about this, and so the practitioners could take advantage.
"Now, more often there is collusion between patients and doctors, and many patients get cash from doctors, who then claim from the medical aid," Mayaba says.
"People commit fraud because of greed, opportunity, need, or lack of ethics. The economic climate in the country is partly linked to need. And the more people are pressed financially, the more they will look for opportunities ."
In recent cases that Medscheme dealt with, pharmacies in Gauteng and KwaZulu Natal were selling baby milk for R96 but claiming R297 from the medical aid.
In another instance, a social worker was de-registered for two years for submitting claims for all the patients in her appointment book long before they even came to consult her.
Marius Smit, chairperson of the Board of Healthcare Funders' forensic management unit, agrees with Mayaba.
"We can expect an increase in member-related fraud, but this has not happened yet. Because the economic conditions have only worsened in the past six months, we think the fraud will only start becoming evident in the next six months."
While most of the fraud (around 70 percent) is service provider related, the remaining 30 percent involves members, brokers and staff within schemes.
When members collude with service providers, they often obtain goods which have nothing to do with healthcare. These include groceries, perfume and sunglasses.
Smit also says some service providers dispense generic drugs to members and then claim the branded drugs' cost from the medical scheme.
Other service providers carry out cosmetic procedures not covered by the medical scheme and then claim for something else.
These procedures include facelifts, breast implants and gold teeth.
But Smit point out that the medical aid industry is increasingly using technology to catch the cheats.
Medical scheme administrators process millions of transactions monthly and are using electronic data analysis and trend analysis to detect fraud.
"Once fraud is detected, it creates quite a significant deterrent. A lot of work has been done around raising awareness, and we're reaping the benefits of it now."
Camilla Singh, a forensic partner at KPMG, which does a medical scheme anti-fraud survey every three years, says collusion between service providers and members "benefits both parties, and because of that it's extremely difficult to prevent and detect".
Mayaba says Medscheme encourages its members to read their statements, and SMSs them to notify them of an imminent claim settlement.
These measures, he says, significantly help to cut fraud where members are unknowingly being taken advantage of.