Medical aid loses R22bn

Sector counts huge losses to fraud, manipulation

The fraudulent usage of medical aid funds to buy personal items such as toiletries or luxuries like branded sunglasses is one of the many things contributing towards a R22bn loss to the industry.

This is according to acting CEO of the Council for Medical Schemes (CMS) Dr Sipho Kabane who spoke to Sowetan ahead of next weeks’s national summit to tackle fraud related to medical aid claims. Yesterday, Kabane said there level of fraud in relation to medical aid benefits was growing at an alarming rate. He said claims amounted to R132bn during 2017 however, 15% of those claims were associated to fraud, waste and abuse. “We believe that if used properly, this is the money that should benefit a lot of people,” Kabane said. He said R29bn claims were rejected during the same period. Kabane said problems occurred in instances whereby practitioners inflated claims, falsified patient records, identity theft and false diagnosis. He said medical aid scheme members also contributed by faking illness and buying luxury items.

“We have cases where people go to pharmacies and buy sunglasses and ornaments instead of medication,” he said. Kabane said as a result the number of members across the country’s 79 schemes had stagnated at 8.8 million people including principal members and their beneficiaries. The summit will bring together experts, industry players and law enforcement to find solutions. Kabane said another problem was fraud in the sector was underreported.