Fraud can also affect your pocket

Did you know that healthcare fraud can contribute directly and indirectly to the rise of medical costs, including your membership contribution? You have the power to help us prevent fraud for the greater good of all our members.

READ WHAT HAPPENED TO SARAH

Sarah* is a stylish, proud mom of three. She has always fitted into a size 10 dress and enjoys spending her money on stiletto shoes. After the birth of her third child, she was struggling to lose the last few kilograms and was longing to fit into her pre-pregnancy clothes. Her friend, Caroline*, had the solution for her. Caroline informed her of the incredible benefit that their medical aid provided, which covered slimming waist bands. She was so excited about this benefit that she shared the news with all her colleagues.

To make it even better, she met a fantastic dietician who goes the extra mile to have the waist band delivered to your house and you can even exchange it for a different size at no extra cost.

Sarah jumped at the opportunity and contacted the dietician on the same day to place her order. She was excited to receive the high-quality waistband delivered and decided to share the tip with even more colleagues – “more people should know about the benefits that their medical aid offers”.

The Forensics department noted a spike in dietician costs paid by the medical scheme. The sophisticated forensic tools flagged Mr. Adam’s* practice as a risk due to numerous factors including the sudden increase in claims, high number of hours billed per day and codes billed being very similar for each consultation. Following the analysis, the Forensic Analyst decided to digitally verify claims submitted with members directly.

The Forensics department sent a message to Sarah to confirm if she had previously consulted with a dietician named Mr. Adams during the month. Confused with the message received as Sarah never met Mr. Adams, Sarah asked her husband to assist.

Below is the email response from her husband:

Sarah and her husband were left speechless after Forensics informed them that Mr. Adams was defrauding their medical scheme by claiming for consultations while providing waist bands to members. Waist bands was not covered by the Scheme as it is not clinically appropriate and necessary.

In future, Sarah and her husband will review their membership statements in detail and report irregular claims to the Scheme hotline.

(*Member and provider name changed for confidentiality purposes.)

HOW TO REPORT FRAUD

Members are encouraged to use any of the dedicated Whistle-blowers hotline reporting channels to report suspected medical aid fraud.

SEVEN WAYS TO MAKE A REPORT TO THE WHISTLE_BLOWER ETHICS HOTLINE

  1. Call directly on toll-free number 0800 112 811
    Use the dedicated Whistle Blowers hotline number to make a report via the live answering service.
  2. SMS to 33490
    Send your report via the sms line from anywhere in South Africa, at a cost of R1.50.
  3. Report online on www.whistleblowing.co.za
    Visit the Whistle-blowers website to report and make your submission via the online reporting platform.
  4. Email to information@whistleblowing.co.za
    Send an email of your report privately to whistle-blowers.
  5. Download and use the Whistle-blowers app
    Download the secure Whistle Blowers app from Google Play or the Apple App Store. The App guides you through the reporting process with ease.
  6. Post a letter of your report
    Send a letter of your report to whistle-blowers via post using the below details:
    Freepost KZN665, Musgrave, South Africa, 4062
  7. Fax your report
    Send your report to whistle-blowers via a fax line: Toll-free on 0800 212 689

REMEMBER, REPORTS CAN BE MADE ANONYMOUSLY OR IN CONFIDENCE.