By rooting out fraudulent claims, Discovery Health saved R568 million for its client schemes last year – up from R405m in 2016.
Discovery Health chief executive Dr Jonathan Broomberg says cracking down on fraud acts as a strong deterrent, resulting in further saving. “We estimate that the ‘halo’ effect of these fraud-control activities, in which health professionals and others contemplating fraud desist from fraud in reaction to visible policing and action by Discovery Health, has prevented additional fraud to the value of approximately R3 billion over the past 24 months.”
Efforts to combat claim fraud include the deployment of a specialised team of analysts and professional investigators, as well as a forensic software system that analyses claims data and identifies unusual claim patterns. Tip-offs from whistle-blowers also help.
Discovery Health says the trends of the top provinces and types of offences remained relatively unchanged. Gauteng (2 595), KwaZulu-Natal (916) and the Western Cape (773) had the highest number of fraud cases last year, with the Northern Cape (five) having the lowest number.
The main offence in 2017 was claims submitted for medicines and medical devices that were never supplied. A common trend involved pharmacies supplying members of medical schemes with non-claimable items but submitting claims for prescription medicines. In other instances, medicines or services were supplied to non-members and were claimed for using a member’s medical scheme card. Sometimes, pharmacies or doctors dispensed generic medicines but claimed for higher-cost original medicines.