Medical Scheme Fraud Is Everyone’s Business

By Josua Joubert, CEO and Principal Officer: CompCare Medical Scheme

Medical scheme fraud and abuse of benefits is a relatively common problem in South Africa, and schemes such as CompCare have to fight an ongoing battle to deal with the problem, which costs the healthcare funding sector millions of lost rands each year.

It should be noted that fraud is conducted by a small minority of stakeholders, including healthcare providers and medical aid members. Fraud can nevertheless represent a serious drain on a scheme’s financial resources. This is not only as a result of funds lost to fraudulent activities directly, but also because fraud compels schemes to put in place the necessary systems to combat it, which can also be costly.

In any case, fraud can seriously impact the sustainability of medical schemes and also potentially result in them having to implement higher annual contribution increases for members. It, therefore, has negative implications for all stakeholders in the medical scheme sector.

We at CompCare believe that we exist to provide cover to our members when they are in need and we, therefore, have to put in place special systems to curb fraud, waste and abuse of benefits. As a not-for-profit organisation, in line with the Medical Schemes Act of 1998, we believe that it is vital that we use all available measures to ensure that all member funds are used effectively and efficiently within the rules of the Scheme.

We are of the view that fraud is everyone’s business and would like to invite all stakeholders including members and providers, to assist us in combating it. They can do this by reporting attempts to defraud medical schemes should they encounter them.

Members can also assist in this by ensuring that they know the scheme rules, as some members do not know the rules and may inadvertently break the law. They would benefit from knowing exactly what is permissible in terms of scheme rules.

Other medical scheme members may feel that their contributions entitle them to gain an advantage at the expense of their medical scheme and other members. In either case, their activities drive up costs, and may negatively impact the financial stability of a scheme.

Healthcare provider fraud also occurs from time to time. Some healthcare providers have been known to submit fraudulent or ‘phantom’ claims. These may be submitted with or without the knowledge of members. In the latter case, members and providers effectively conspire in order to defraud a medical scheme. Other fraudulent activities that have been identified include over-servicing and incorrect prescription submissions.

Scheme members should follow these guidelines to help prevent fraud and irregular claiming:

  • Never give your membership card, or a copy thereof, to any other person.
  • Check your medical scheme statements for any discrepancies or irregularities.
  • Ensure the medicines that you get from your pharmacy are what were prescribed to you.
  • Check that the diagnosis code on the claim is the same as that which was provided to you.
  • Check that the statement that you sign has all details correct.
  • You should speak out and challenge invoices if you have any concerns and can see that services and/or treatments were not what was provided.
  • Ensure that your dependents are aware of the scheme rules and do not abuse their benefits.
  • If you are in any doubt about a transaction please don’t hesitate to contact your medical scheme.
  • Report suspicious and fraudulent activities to the CompCare fraud line.

CompCare has zero-tolerance of healthcare fraud, which costs the industry heavily every year, and is committed to countering it at every turn. We believe that this menace can only be combated if all stakeholders work together and invite all South Africans to join us in the fight against health fraud.

 Are you concerned about fraud? Please reach out to us via our 24/7/36 Vuvuzela Hotline which forms part of CompCare’s commitment to zero tolerance when it comes to dishonest and unethical behaviour.

Toll free number: 080 111 4447
Fax: 086 672 1681
E-mail: [email protected]
Callback: 072 595 9139