Make sure you don’t accidentally commit fraud

Medical scheme fraud is a growing problem in South Africa and is a contributing factor in the increase in healthcare costs. Sometimes service providers commit fraud, and other times the members themselves do so. In some cases, these two parties may even work together to defraud a medical scheme so that they can both gain.

While some incidences are quite flagrant, in some situations you as member may not even be aware that fraud is being committed ‘in your name’. It is important to remember that fraud – even the more ‘innocent’ cases – is illegal and that you may be prosecuted if you are found guilty of committing fraud.

Examples of service providers committing fraud (with or without the member’s knowledge and ‘co-operation’)

  • Submitting claims for services that have not been rendered (sometimes in return for a cash payment to the member).
  • Manipulating claim codes to charge for a more expensive procedure than the one provided, charging codes for services not provided, or claiming for non-covered benefits under codes that are covered.
  • Providing services that are not necessary, simply to be able to claim.
  • Dispensing low-cost generic medicines, but claiming for more expensive brand-name medicines.
  • Providing fraudulent sick notes to members without even seeing them and then claiming for a consultation.
  • In the case of pharmacies, selling cosmetics and other non-medical items to scheme members and then submitting fraudulent claims for medicines.
  • Doctors and hospital employees, with the collusion of the member, submitting claims for false hospital admissions.
  • Where the member’s benefits had been depleted, holding back a claim and changing the service date so that the claim could be paid from the following benefit year’s benefits.

Examples of members committing fraud

  • When they join, not disclosing previously existing medical conditions.
  • Belonging to (and therefore potentially claiming from) more than one medical scheme.
  • Colluding with service providers, for example by forging and submitting claims for services supposedly rendered by healthcare professionals, but never actually rendered.
  • Altering amounts on invoices they have paid, and claiming a higher amount.
  • Lending their medical scheme card to people other than their registered dependants to use.

What you can do to help fight fraud

  • Check the accounts you receive from medical service providers for errors or inconsistencies.
  • Check your member statement, sms notifications and emails from the Scheme to make sure that any claims that have been processed are correct and that there are no claims for services not provided.
  • If you suspect any fraud, please call the Fraud Hotline on 0800 112 811, or email fraud@medscheme.co.za.