BUSINESS MAVERICK: Medical aid schemes caught in a vice between fraud and claims of racial profiling

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BUSINESS MAVERICK: Medical aid schemes caught in a vice between fraud and claims of racial profiling By Tim Cohen

All insurance companies face a high level of fraud, but it’s a little-known fact that it’s an extreme problem for medical aid schemes. Recently at the Council for Medical Schemes’ inaugural Fraud, Waste and Abuse Summit, it was estimated that fraudulent practices cost members somewhere between R22-billion and R28-billion a year.

Why is this so high? For one thing, medical aid fraud is kinda easy. With an insurance claim on a car that has been in an accident, for example, the value of the damage is comparatively simple to quantify and the evidence of the accident is most often very obvious. Some of the claims are simply stupid. One doctor claimed he was treating 50 patients a day. But mostly, the way medical aid schemes find out about it is through tip-offs by patients. About 53% of fraudulent claims are discovered in this way and the remainder is found out by applying statistical algorithms.

This week, a hearing was held at the Human Rights Commission, where Dr Donald Gumede, chairperson of the National Health Care Professionals Association made allegations of “racial profiling”.

 

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