One of the largest medical aid administrators in the country, Medscheme, is responsible for the administration of 11 schemes including
“That’s a conservative estimate because the exact number is hard to quantify. Some companies say anything from 5% to 15% of healthcare claims could include an element of fraud, waste and abuse,” she says. “Fraud also contributes to the cost of healthcare increasing due to the heavy claims paid out. Many of these have come to light due to whistle-blowers, as well as investigations aimed at identifying the causes of increasing healthcare costs in the country,” Strydom notes.Fraud is a deliberate act with the intention to defraud someone; where person A is unduly benefited at the expense of person B and the key is intent.
However, some “fraudulent” claims arise simply from error. For example, duplicate claims could occur due to system errors or miscommunication between the doctor and the secretary or the billing agency. “That level of proof is difficult in the healthcare environment. Healthcare professionals need to be paid before they provide a service, even in the case of hospitalisation or emergency care. This means that medical schemes have to trust medical professionals to be honest and that submitted claims are valid.
“In this case, the dentist did two bridges and then told the member he would claim for one bridge in the current benefit year and the second bridge in the next benefit year. The rationalisation is that you could be doing the two bridges over two years, but you are doing the work in one go and spreading the claim.
Many people knows what some Drs and hospitals do should you be on a medical scheme..