Sundaymail Editor
LAST week, we discussed fraud and waste.
This week, we will focus on abuse and errors. We will explore how these issues, alongside fraud and waste, can threaten the sustainability of the fund and deplete your member benefits.
Abuse
Abuse occurs when members seek healthcare services unnecessarily. For example, visiting a doctor to obtain an “off-sick” note for social reasons instead of taking personal leave is considered abuse of the medical aid benefit.
Some individuals may even visit doctors simply for companionship, without any medical need. This overutilisation of healthcare services, without a legitimate reason, harms the system and your personal benefits.
On the service provider’s side, abuse happens when medical best practices are not followed, leading to unnecessary treatments or overprescribing.
In some cases, service providers may also intentionally use a higher tariff code to claim more than the standard rate, increasing costs unnecessarily.
Another common form of abuse involves healthcare providers ordering excessive tests, especially when they have ties with diagnostic units such as laboratories or X-ray facilities. These tests may not be medically necessary but are performed to increase revenue by “pushing numbers”.
Error
Error refers to unintentional mistakes, such as when a service provider uses the wrong tariff code or enters an incorrect member number. While these are genuine errors, they can still lead to incorrect billing, resulting in unnecessary costs for the fund and delays in claims processing.
Implications of fraud, waste, abuse and error
Fraud, waste, abuse and error all lead to significant financial losses for the fund, threatening its long-term viability and sustainability. For members, these issues can cause the depletion of your benefits, leaving you without coverage when you need it most.
For instance, visiting emergency rooms or 24-hour medical units for minor ailments can quickly use up your hospital benefits, which should be reserved for genuine emergencies such as accidents or critical hospitalisations. This early exhaustion of benefits could mean that, when a real emergency arises, you might not have the financial support you need.
In addition, healthcare fraud is a criminal offence and can lead to prosecution, with severe consequences for those found guilty.
Your role as a member
As a member, it is your responsibility to understand how your medical aid works. Ensure you are aware of your package’s benefits and the global limits that apply to your coverage.
If you are unsure about what is covered, do not hesitate to ask your medical aid provider for detailed information.
You also have the right to information from your service provider regarding your health and the treatments being provided. Always ask about your diagnosis, the tests being ordered and the reasons behind those tests. Transparency from both your medical aid and healthcare providers is key to preventing abuse and errors.
For more information, feedback
If you have any questions or need further clarification on the information shared here, please contact us at: [email protected]
You can also visit the PSMAS website or download the PSMAS 24/7 mobile app from Google Play or the App Store to find a provider near you. Alternatively, reach us via WhatsApp at 0783 183 530 for quick assistance.
Conclusion
By understanding the effects of fraud, waste, abuse and error, you can help safeguard the sustainability of your fund and ensure that your benefits are preserved for the time when you truly need them.
Remember, prevention starts with awareness and responsible use of healthcare services. Stay informed, ask questions and always seek clarity on your medical needs to help protect the fund and your benefits.
Online Reporter