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CIMAS Medical Aid says health and medical aid fraud were a global phenomenon and by Southern African estimates, it would mean the company may have lost nearly $80 million over the last two years. The firm’s audit manager, Thando Kembo told an insurance workshop for journalists that medical aid and health insurance frauds were a global problem and not reflection of the state of an economy.
She pointed out that fraudulent claims occurred worldwide even in countries that have sound economies and it was unlikely that fraudulent claims would go away. It was, she said, like a chronic disease.
Ms Kembo said that was it a considerable sum, equivalent to more than 12 percent of the Government’s budgeted healthcare expenditure for 2016 or 19 percent of the budgeted expenditure for 2017.
Fraud referred to an illegal or irregular act committed by people to secure personal or financial advantage.
“It is just someone who has found a way of getting more money than they should,” she said.
Medical aid fraud could be perpetrated by service providers, medical aid society members and staff, the Cimas audit manager said.
Fraud by service providers included claims for services not rendered, charging for branded medicines when cheaper generic medicines have been dispensed and incorrect reporting of diagnoses or procedures.
Such acts also included misrepresenting dates, tariff times and location of service delivery in order to charge for the service at a higher rate.
Over-utilisation of services, over-servicing through unnecessary procedures and false or unnecessary issuing of prescription drugs are also considered among common acts of medical aid frauds.
Fraud by medical aid society members chiefly involved use non-members to their membership card. It also entails collusion between members and service providers in the submission of false claims.
Ms Kembo said fraud by staff members was less common and easier to keep a check on. It generally involved soliciting a kickback to process fraudulent claims or give favours for service delivery.
She cited fraudulent gain by service providers through unnecessary procedures in other countries, such as a surgeon in the United Kingdom recently convicted of intentionally wounding patients by carrying out unnecessary mastectomies, surgically removing breasts of women when there was no need to do so.
In a similar case of fraud, a senior orthopaedic surgeon on the United Kingdom is being investigated for billing for operations that were carried out, but were suspected to have been unnecessary.
Cimas said it had embarked on educating members, service providers, staff and the public on common fraud schemes to prevent them.
Cimas was also continuously improving its own controls to safeguard members’ funds against any malpractices that came to its attention.
The medical insurer was also engaging global players in order to remain informed about common fraud schemes in other parts of the world.
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