Jig is up for med­i­cal aid scam­mers

CityPress - - News - ZINHLE MAPUMULO zinhle.mapumulo@city­press.co.za

Med­i­cal fraud­sters be­ware. In­sur­ance com­pa­nies are watch­ing you. They know your “ur­gent hos­pi­tal stay” was ac­tu­ally a chance to chill – and pocket some cash. Take the cases of two Dis­cov­ery med­i­cal scheme mem­bers. One was ad­mit­ted for vom­it­ing and heart­burn af­ter eat­ing a cheese-and-tomato sand­wich. The di­ag­no­sis changed from in­di­ges­tion to in­fec­tious di­ar­rhoea. He re­ceived a sin­gle dose of Imod­ium and an­tibi­otics ad­min­is­tered in­tra­venously, and re­mained in hos­pi­tal for five days.

An­other Dis­cov­ery mem­ber was ad­mit­ted to hos­pi­tal for asthma, al­though the ca­su­alty ad­mis­sion notes made no men­tion of wheez­ing or res­pi­ra­tory dis­tress. On the third day in hos­pi­tal, a phys­io­ther­a­pist treated the pa­tient for lower back pain – but no men­tion of back pain was cited in the nurse’s notes. In­stead, the notes said the mem­ber asked to be ad­mit­ted to hos­pi­tal.

Both mem­bers had a hos­pi­tal cash­back pol­icy. This is a pop­u­lar prod­uct sold by in­sur­ance com­pa­nies that pro­vides ben­e­fi­cia­ries with a lump sum of between R3 000 and R5 000 if they are hos­pi­talised longer, usu­ally, than three days.

The cash­back plans are in­tended to help cover the short­fall a pa­tient might face if their hos­pi­tal costs are not fully cov­ered by their med­i­cal aid schemes.

But some un­scrupu­lous pol­i­cy­hold­ers, work­ing with doc­tors and hos­pi­tals, are us­ing it to en­rich them­selves. And in the process, med­i­cal schemes and long-term in­sur­ance providers are los­ing mil­lions.

Mar­ius Smit, the head of foren­sic ser­vices at Dis­cov­ery Health, said it was dif­fi­cult to give ac­cu­rate fig­ures on how much the scheme was los­ing as a re­sult of this.

“But Dis­cov­ery Health re­cov­ered more than R288 mil­lion from all types of fraud­u­lent med­i­cal claims last year,” he said.

Lat­est statis­tics from the As­so­ci­a­tion for Sav­ings and In­vest­ment SA (Asisa), which rep­re­sents life in­sur­ers, show that 375 cases of hos­pi­tal cash­back-plan fraud, to­talling R3.8 mil­lion, were recorded in 2012. It could have been worse. There were 549 cases in 2011, to­talling R4 mil­lion.

Last year’s statis­tics are still be­ing fi­nalised by the as­so­ci­a­tion, but Brad Frank, a pol­icy ad­viser at Asisa, said he be­lieved the fig­ures would in­crease. “KwaZulu-Natal re­mains the hot spot, but we are see­ing a grow­ing trend in Lim­popo and Gaut­eng as well,” he said.

Smit agreed, say­ing Dis­cov­ery’s foren­sic team has noted the trend in all three prov­inces. “Dis­cov­ery Health has a team of ... in­ves­ti­ga­tors and an­a­lysts who are able to iden­tify and de­tect anom­alies and outliers within the scheme claims data,” he said.

Ac­cord­ing to Smit, data com­piled by foren­sic in­ves­ti­ga­tors show that, on av­er­age, peo­ple in­tend­ing to milk the scheme are ad­mit­ted to hos­pi­tal five times more of­ten than those who don’t have cash­back in­sur­ance. Their hos­pi­tal stays are also 40% to 60% longer.

Some mem­bers im­pli­cated in the scam were ex­pelled from the scheme and now face crim­i­nal charges. Smit said: “In­ves­ti­ga­tions are in progress and we are work­ing with the med­i­cal prac­ti­tion­ers and hos­pi­tals to re­solve th­ese is­sues.”

Peter Ker­ford, the head of foren­sic in­ves­ti­ga­tions at in­sur­ance firm MMI Hold­ings, which also of­fers hos­pi­tal cash­back plans, said it was dif­fi­cult for in­sur­ers to com­bat this be­cause they “do not have the pre-au­tho­ri­sa­tion pro­cesses that med­i­cal schemes have”.

“We only re­ceive claims af­ter a per­son has been ad­mit­ted. But schemes have this process and can alert us when they sus­pect some­thing,” he said.

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