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Fraudulent medical aid claims

A recent article on the Health24 website had me reaching for heart pills I do not have.

Discovery Health CEO, Dr Jonathan Broomberg, revealed that his company recovered R400 million on behalf of its client schemes. Discovery Health’s Forensics department deals with more than 3 000 forensic investigations per year.

“Doctors were identified who were admitting patients, who were not ill, to hospital, then submitting false claims on their behalf to both their medical scheme and their cash plan provider. The ‘patient’ would then split the cash lump sum paid out by the insurer with the doctors,” said Dr Broomberg.

When asked what the fraud claim hotspots were, he named six frequent fake claims:

  1. Doctors submit claims for services that have not been rendered to patients.
  2. Dispensing doctors and pharmacies provide members with low cost generic medicines and claim for higher cost brand name medicines.
  3. Doctors provide fraudulent sick notes to members and then claim for a consultation from the scheme.
  4. Pharmacies sell cosmetics and other “front shop” items to scheme members, and submit fraudulent claims for medicines to the scheme.
  5. Members, in collusion with doctors and hospitals, submit claims for false hospital admissions, in order to benefit from the claims payment.
  6. Members forge and submit claims for services supposedly rendered by healthcare professionals, but which were never actually rendered.

What happens to members and medical professionals involved in fraud?

When fraud is identified and proven, Discovery Health takes a number of actions, explained Dr Broomberg.

The scheme reclaims the monies obtained fraudulently by members and healthcare providers, and which are owed to the medical scheme. The scheme then terminates memberships of clients and payment to healthcare providers in the cases of proven fraud and they also file formal charges of fraud where appropriate with the South African Police Services.

Regarding fraud by medical professionals, Discovery Health submits formal complaints to the Health Professions Council of South Africa (HPCSA) where appropriate. “The HPCSA has jurisdiction to dismiss or suspend a healthcare professional according to the merits of the case,” Dr Broomberg said.

Is this the same profession we had such high regard for, not so long ago?

Click here to read the full article.

One Response to Fraudulent medical aid claims

  1. Steve Weiss 27 June 2016 at 6:10 am #

    How does the cost of administration of the Discovery Health scheme compare to the moneys recovered from fraudulent claims. Perhaps the claim by some observers that Discovery is not giving value for money for the administration fees that it charges needs to be seen in this light. In addition, the Health Plan Protector benefit, which Discovery offers, gives one an opportunity to recover 80% of unused in hospital contributions plus contribution waiver for up to ten years due to death, disability, or severe illness of the principal member and spouse.