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Medical scheme fraud, estimated at about R15bn annually, is not declining, despite greater sharing of information by medical schemes and a zero-tolerance approach by some of the bigger medical schemes such as the Government Employees Medical Scheme and Discovery Health.
Michelle David, a medical scheme specialist at law firm Eversheds, said on Friday although it had been estimated that fraud cost SA’s schemes between R4bn and R15bn, she believed it to be more than R15bn. She said few medical schemes took part in surveys to determine the extent of fraud — only about eight schemes on average, and not the larger ones. Discovery Health CEO Jonathan Broomberg said yesterday that although figures bandied about were “nothing more than guesswork” it was a “significant and growing problem”. Discovery Health recovered about R250m from fraud it could prove every year, and the scheme spent “significantly more” than R10m a year to investigate and combat fraud, he said.
Board of Healthcare Funders spokeswoman Heidi Kruger said 10% of the R90bn annual spend in private healthcare — covering only 16% of people in SA — could be attribut ed to fraud and wastage. A KPMG report showed that of the R145bn spent on medical treatments from 2007 to 2009, more than R67m was leakage due to fraud committed by members and almost R152m because of fraud by service providers. According to Ms David, statistics from the South African Medical Association showed that R150 of a member’s average contribution in 2002 went to combating and covering losses due to fraud. This increased to R400 in 2010. Lynette Swanepoel, manager of the Board of Healthcare Funders’ forensic management unit, said on Friday she personally had little faith in surveys that indicated a decline in fraud. There has simply been a change in the methods used by fraudsters.
“We are seeing more syndicated fraud than (by) individual doctors or partnerships. We see more and more a hospital, doctor and pharmacy involved, with scouts out there just collecting medical scheme numbers of people.” Ms David said the level of fraud was quite “ludicrous”. Doctors were overbilling, pharmacists were dispensing medicine patients never asked for, and members were getting cash, groceries and even very expensive cooking pots through their medical schemes. “The introduction of the National Health Insurance (NHI) will bring a whole new level of access. You currently have 16% of the population covered by private healthcare and the balance are in the public hospital system … as it stands, it is already riddled with fraud,” she said. A positive element of the NHI plan is that it would be “one bank of information” and would therefore not suffer the same level of manipulation as different schemes not eager to share information were suffering, Ms David said.
Ms Swanepoel said: “There are huge concerns about systemic fraud showing its ugly face in the NHI where the volume of service providers, members and claims are going to be multitudes of what the current situation is.” All medical schemes and administrators were looking at ways to assist the government in setting up a system that could help combat fraud. “The sheer volume expected in the NHI is a major concern. Right now we are not even catching everything in the loop, so it will have to be a strong task force to monitor fraudulent activities,” Ms Swanepoel said. Ms David said the various laws that governed medical schemes, healthcare professionals and the criminal justice system did not “speak to each other”. As a result, medical schemes were “toothless”, and this raised concerns if the NHI scheme was to be run under the same laws. The government would have to be alert to the current shortcomings in legislation and enforcement, Ms David said. Ms Kruger suggested “systemic changes” in the industry to get rid of the wastage and fraud.