
CMS moves to rein in how medical schemes investigate fraud
Circular 10 introduces interim rules to standardise audits, investigations, and clawbacks as broader reforms are developed.

Circular 10 introduces interim rules to standardise audits, investigations, and clawbacks as broader reforms are developed.

The CMS frames the judgment as necessary to protect members, emphasising the scheme is compliant, operational and under close oversight.

The scheme and the regulator say a narrowly focused investigation will not halt the transition – but members should brace for some operational changes.

Bonitas’ decision to change administrators comes amid a CMS investigation and High Court proceedings involving its former service provider.

Discovery Health has abandoned recovery action against more than 16 500 members, agreeing to absorb up to R170 million in overpaid ATB claims after sustained pressure from MediCheck,

Discovery Health is engaging affected members individually after a processing error led to some pharmacy claims being paid beyond Above Threshold Benefit limits during 2025.