Pre-NHI forum to take on medical aid graft

The Special Investigations Unit (SIU) has teamed up with the private healthcare industry to create a forum to help detect and prevent corruption and abuse in preparation for National Health Insurance (NHI).

Fraud, waste and abuse in healthcare remain challenges in the well-funded private healthcare sector, which faces risks from both patients and healthcare providers, with the industry losing billions every year.

The Board of Healthcare Funders’ (BHF’s) 18th annual conference is under way in Cape Town and these risks formed part of the discussions on Tuesday. The event has been addressed by both local and international experts.

SIU head Andy Mothibi said the unit had been in talks with various associations in private healthcare about the creation of a joint forum that would result in law enforcement agencies and funders collaborating to prevent criminal activity.

Data generated by the BHF suggest that about 7% of all medical aid claims are fraudulent. It is estimated fraud costs the private sector R22bn a year — compared with about R24bn in irregular expenditure recorded for provincial health departments in 2009-13.

Health Minister Aaron Motsoaledi has released the white paper on NHI, which proposes that all public funds be pooled. These funds, experts say, will need to be protected.

Mothibi said the SIU would be signing a memorandum of understanding with stakeholders including the Council of Medical Schemes, the BHF and the Health Professions Council of SA to come up with strategies the forum would deploy.

Prevention was key in fighting fraud and waste and the forum would collaborate to mitigate risk under NHI.

“Our view is that this space [healthcare funding] deserves attention,” Mothibi said.

Gregory Pratt, senior clinical adviser at Medscheme’s forensic unit, said fraud and abuse posed a material threat to the affordability and sustainability of medical schemes, and to any national insurance scheme.

There was an entitlement factor among doctors who sometimes charged triple the amount for patients who suffered a condition covered under the prescribed minimum benefits, Pratt said.

He cited a psychologist charging R4.3m in 102 days, pharmacies in Soweto claiming more than R100m in three years and more than R5m being paid to a radiographer in one year, as examples of how practitioners abused the system.

The enforcement of codes of ethics was critical at this point because fraud, waste and abuse would seep into NHI.