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Examples of alleged fraud committed against GEMS

Medical aid fraud is one of the largest growing problems that we are faced with in South Africa, as it contributes to the overall cost of healthcare and occurs right across the board. The drivers of fraud include:

• members
• healthcare providers
• employees and
• other stakeholders.

Actual examples of alleged fraud committed against GEMS by healthcare providers:

• Dental therapist: A Department hosted a Health and Awareness Day. A dental therapist was one of several healthcare providers invited by the Department to offer his services to its employees. All consultation services were paid by the Department. The dental therapist rendered dental services to members and claimed for these as well as additional procedures not performed from GEMS, despite having been paid by the Department already.
• Social worker: A social worker was submitting claims for services not rendered to GEMS. Members visited the provider in 2007 and claims were submitted and settled. Duplicate claims were submitted for the same members with the service date changed to 2008. The members never visited the provider in 2008.
• There were articles published in various newspapers on a National Prosecuting Authority (NPA) media statement concerning a pharmacist and general practitioner who were arrested on charges of fraud against numerous schemes. The pharmacist would sell groceries and other items, at inflated prices, to members of various medical aid schemes. The members would "pay" for the items purchased by allowing the pharmacist, through his various pharmacies, to submit fictitious claims on their behalf to their medical aid schemes. To "legitimise" the fictitious claims, the general practitioner would provide the pharmacist with prescriptions for medication for the member without a valid medical consultation having taken place.
• General Practitioner: Charging for services not rendered, e.g. claiming for a consultation when the member never consulted with the provider.
• Optometrist: Charging for higher cost lenses than those provided to the members and also for services not rendered.
• Pharmacy: Submitted claims for medication not dispensed, in lieu of the payment of levies by members.

Actual examples of alleged fraud committed against GEMS by members/non-members

• A member allowed her sister to use her medical aid card to obtained ante-natal treatment. The member also allowed her mother to purchase over-the-counter medication on her medical aid despite the fact that the mother is registered as a principal member under another membership number.
• A member obtained HIV benefits fraudulently and provided baby milk to a non-registered dependant.
• A member has admitted a family member who was not a dependant on GEMS under her son's dependant code. A claim was submitted under her son's dependant code.
• An individual who was not a registered member of GEMS, used a GEMS membership card at a practice and received medical services.