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Types of fraud

Examples of types of fraud committed by healthcare providers and/or members:

• Manipulating duplicate claims.
• Billing for services not provided.
• Cash loans. Example: Healthcare providers handing out cash to members for submitting a claim to the medical scheme.
• Dispensing merchandise to patients. Example: Pharmacies dispensing groceries to members and then claiming for medicine from the medical scheme.
• Provider syndicates sharing members' numbers and submitting false claims for members never consulted with.
• Billing for brand name medicine while providing the member with cheaper generic medicine.
• Altering or tampering with prescriptions by pharmacies. Example: Two types of medicine are prescribed, recorded on the script and dispensed. The pharmacy enters two additional types of medicine on the script and claims for more.
• Re-submitting claims that have been rejected previously, for example changing the claims information on rejected claims and re-submitting until these meet the scheme rules and are paid.
• Kickbacks. Provider is receiving cash paybacks for referring patients to a specific hospital or healthcare provider.
• Charging more than once for the same service.
• Claiming for services already paid.
• Dispensing sunglasses but claim for lenses or contact lenses.
• Over servicing, e.g. a provider requests patients to come back for a follow up visit unnecessarily.
• Using invalid tariff codes.
• Inflating of claims.
• Billing for different package sizes.
• Disguised treatment.
• Dispensing excessive quantities of medicine.
• Medical scheme card fraudulently used, e.g. member is lending out his medical scheme card to family members or friends who are not registered to use the benefits of the medical scheme.
• Collusion.
• Abuse of benefits.
• Fraudulent foreign claims.
• Enrolling ineligible people for coverage.
• Dual membership, e.g. member belonging to two medical aid schemes at the same time.
• Non-disclosure of prior ailments on an application form.