Crackdown on medical aid fraud saves millions

HALF-a-billion rand.

That is what Discovery Health administrators claimed they had saved Discovery – and other medical aids – by uncovering fraud and recovering ill-spent money.

But Discovery Health said there was probably a few more billion rand wasted through fraud that was never uncovered each year. The R568-million recovered was up from R405-million in 2016.

The main offence in 2017 was members and health workers submitting claims for services that had not been offered‚ or pharmacies and members claiming for medicines and medical devices that were never supplied.

“Pharmacies supply members of medical schemes with nonclaimable items such as baby formula‚ nappies‚ cosmetics and shoes yet submit claims for prescription medicines.

“Sometimes pharmacies or doctors dispense generic medicines‚ yet claim for higher cost original medicines.”

Another type of common fraud was when doctors‚ dentists‚ therapists or pharmacies gave services to someone who didn’t belong to the medical aid by using an actual member’s medical aid details.

Hospital cash back policies were also a main driver of fraud. These insurance schemes often pay R3 000 or R5 000 to a person for each day they spend in hospital to cover loss of earnings or supplement their medical aids. In order to make money‚ dodgy doctors admit “patients” who are not sick to hospital.

The “patients” claim from medical aids‚ who then pay for the unnecessary hospital stay‚ and then the “patient” and doctor make money from this cash back payment.

Discovery Health uses a specialised team of over 100 analysts and professional investigators to uncover fraud. — DDC