Losses close to R4 bln

MED­I­CAL AID: Fraud so big it ‘can­not be quan­ti­fied’

Weekend Witness - - Money -

FRAUD had gained an un­healthy foothold in the pri­vate health­care in­dus­try to such an ex­tent that it could not even be quan­ti­fied, said Dr Guni Goolab, prin­ci­pal of­fi­cer of the Govern­ment Em­ploy­ees Med­i­cal Scheme (GEMS).

“The les­son is clear: we have to give voice to our ab­so­lute op­po­si­tion to med­i­cal schemes abuse and fraud.” he said in his clos­ing ad­dress at the scheme’s an­nual con­fer­ence held in Cape Town this week.

“It has been es­ti­mated that losses due to fraud in South Africa are in the re­gion of R4,1 bil­lion. This is much too high a price to pay, par­tic­u­larly for a fledg­ling econ­omy such as ours,” he said.

Dr Goolab said fraud ar­ti­fi­cially in­flates health­care costs. The higher the cost of fraud the less there is avail­able to spend on mem­bers’ health­care needs, he said.

Mem­bers of med­i­cal schemes had the right to know what was hap­pen­ing to their con­tri­bu­tion fees and what was be­ing done to stem the un­wel­come tide of abuse and fraud.

“We need to en­gage mem­bers fully in our quest to di­min­ish this scourge. But first and fore­most, we need to un­der­stand the true ex­tent of the prob­lem. That is why some­thing tan­gi­ble needs to be put in place at in­dus­try level to record and re­port ac­tual losses as a re­sult of fraud­u­lent ac­tiv­ity.

“At present one of the great­est chal­lenges in the in­dus­try is a lack of co-op­er­a­tion and in­volve­ment on the part of mem­bers,” he said.

“Mem­ber ed­u­ca­tion pro­grammes and ac­tive en­gage­ment can go a long way to­wards im­prov­ing this sit­u­a­tion. Mem­bers must fully grasp what is at stake and need to un­der­stand the crim­i­nal­ity of fraud and med­i­cal schemes abuse.”

Dr Goolab said mem­bers still per­ceived med­i­cal schemes fraud as a vic­tim­less crime. They mis­tak­enly be­lieved that by per­pe­trat­ing this crime no real harm was be­ing done.

Peter Goss of Price­wa­ter­house­Coop­ers (PWC) said at the con­fer­ence that “a game changer” was needed when it came to med­i­cal schemes fraud.

He said that fraud was an act of de­priv­ing peo­ple of a fun­da­men­tal hu­man right.

One way of putting it to an end is to make it an obli­ga­tion to re­port med­i­cal schemes fraud by ren­der­ing it a statu­tory of­fence, he said.

— Fin24 and Wit­ness Re­porter.

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