Spotlight on medical aid fraud

Schemes are seeking stiffer penalties for guilty doctors

MEDICAL aid schemes have criticised the Health Professions Council of South Africa (HPCSA) for handing down fines of R20 000 and less to doctors found guilty of multiple counts of fraud.

A number of doctors are among the healthcare professionals sanctioned by the council, none of whom were suspended from practising.

The Board of Healthcare Funders (BHF), which represents medical aid schemes, felt the council was “losing the war” on medical aid fraud.

The council regulates healthcare practitioners, but Elmarie Jensen, marketing manager of Genesis medical aid, argued it was failing to deal with doctors who defrauded schemes.

In June, the council found at least five Durban doctors guilty of fraud. One of the doctors faced 26 counts and was fined R70 000, with R50 000 suspended for five years, resulting in an effective fine of R20 000.

The doctor had charged Genesis for services not rendered between 2012 and 2013, causing it financial prejudice.

Another doctor made four claims from medical aids for medication which was not dispensed. The council fined him R40 000, with R20 000 suspended for three years.

A third doctor, found guilty on three counts, was fined R20 000, with R10 000 suspended for three years.

Two other doctors were fined a combined R100 000 for 13 counts, but R80 000 was suspended for five years.

“Wider consequences, such as suspension from practising, is one way that could scare would-be perpetrators from defrauding the schemes,” said Jensen.

She said irregular practices and fraud by medical practitioners amounted to billions of rand annually, and were a financial burden contributing to the overall cost of private healthcare in South Africa.

“All members of existing medical aid schemes foot this bill. We have experienced this type of fraud. A recent incident involved a Cape Town dentist. Our internal clinical auditors detected an unusual trend in claims from this dentist. He claimed about R120 000 for treating just four families during 2014/15,” Jensen said.

Dr Jonathan Broomberg, Discovery Health’s chief executive, said the levels of fraud in the medical aid industry remained at “concerning levels”.

“Discovery Health recovers more than R400m per annum in fraudulent claims of various types. It is important to note that only a small minority of health professionals and members commit fraud,” he said.

Questions on this issue were sent to the HPCSA on Thursday. The council had promised to respond by yesterday, but had not done so.