malvernmugadzikwa
Emmanuel Kafe
Cartels comprising corrupt pharmacists and medical doctors are allegedly submitting fake medical aid claims, resulting in an estimated annual loss of up to US$57 million for private healthcare funders.
According to the Association of Healthcare Funders of Zimbabwe (AHFoZ), suspected fraudulent medical aid claims are bleeding medical aid societies up to 35 percent of the US$164 million they pay out in claims annually.
In an interview with The Sunday Mail on the sidelines of the organisation’s annual Fraud Indaba last week, AHFoZ board chairperson Mr Stanford Sisya cited fraud, waste and abuse as a “triple threat” draining healthcare funders’ resources.
He said fraudulent claims were particularly prevalent.
“One of the things that we have noted is that fraud, waste and abuse are the biggest evils in our industry, whereby we are looking at as high as up to 30 to 35 percent of revenues lost through those three, While we recover nearly half a million dollars quarterly in fraudulent claims detected across the industry, we believe the actual figure is much higher.”
The syndicates, he said, operate by generating fake medical aid claims before receiving payments for services never rendered.
In some cases, he added, specialists may not even see patients, yet their offices submit claim requests.
Mr Sisya said adopting technology will aid in identifying the fraudulent activities. “We are encouraging our members to go digital to ensure that we pick up these bad practices that are happening in the industry,” he said.
“When you look at it, some of the issues have to do with over-servicing, where people don’t need a particular service, but there are cartels who collude to over-service a client by offering them services they don’t need.”
In South Africa, Dr Hleli Nhlapo, chairperson of the Board of Healthcare Funders (BHF)’s Healthcare Forensic Management Unit (HFMU), said there was need for strong collaboration in combating fraud.
“Collaboration is key to addressing fraud effectively,” he said. “By working together and sharing information, we can gain a better understanding of the larger picture and identify trends that may not be apparent when working in isolation. In South Africa, we have established a portal within BHF that enables the HFMU to log and share suspicious cases within the industry, promoting a unified approach to tackling fraud.”
In an interview, Medical and Dental Private Practitioners of Zimbabwe Association president Dr Johannes Marisa said the accusations were unjustified and misdirected.
“Instead of addressing the genuine issues, they are scapegoating us for their failure to compensate service providers,” he said. “If there are instances of fraud, we encourage them to report it to the appropriate authorities and let the legal system handle it.
“The real issue at hand is that medical aid societies are refusing to pay service providers for their services, ultimately affecting patients, who are caught in the middle.”
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