Medscheme article a misrepresentation

THE Board of Healthcare Funders (BHF) says at least 10 to 15% of medical aid claims are fraudulent, abusive or wasteful in nature, a substantial expense in a R150 billion industry. The total fraud costs in the South African private healthcare system are estimated at R22bn each year.

It is a pity that instead of dealing with this national pandemic of looting, some medical practitioners have resorted to diverting attention away from fraud, waste and abuse.

Judging by the headline “Medscheme cited for unfair practices” (Daily News, January 28), it seems that it is the medical aid companies that are at fault. The story was heavy on conjecture and an unfair misrepresentation of the facts.

Over the past three years, Medscheme has recovered more than R741.9 million from fraud, waste and abuse cases. There has never been any evidence that doctors are being victimised. However, the recovery of R741.9m and the R22bn fraud cost is proof that it is medical schemes that have suffered financially because of fraudulent claims.

We point out the following: The National Healthcare Professionals Association (NHPA) brought an application in the high court against Medscheme and other healthcare providers, requesting that our forensic processes be declared unlawful and unconstitutional.

The case was dismissed. They were also denied leave to appeal. The court said they had no reasonable prospects of success.

The losing applicants, including Donald Gumede, one of the sources of the story, now face personal costs for reckless litigation.

Jimmy Mufamadi is being investigated after being paid more than R20m over two years by medical schemes for submitting claims for appliances and services.

The truth is that due to the urgent and immediate healthcare needs of our clients, payments are made on the basis of trust and goodwill. Unlike other insurance sectors, where an assessor first assesses a claim to determine its validity, we have to pay first and check validity later. This exposes the medical aid industry to a greater degree of fraud, waste and abuse.

Medscheme will continue to collaborate with healthcare professionals, regulators, industry bodies and all stakeholders to reduce fraud waste and abuse, provide sustainable healthcare and reduce the costs of services in our country. ANTHONY PEDERSON CEO Medscheme