Time to voice opposition to medical schemes abuse

Friday, 16 August 2013

Government Employees Medical Scheme's conference a solid starting point from which to tackle the scourge of fraud

"Fraud has gained an unhealthy foothold in the private healthcare industry to the extent that we cannot even begin to quantify it. The lesson is clear: we have to give voice to our absolute opposition to medical schemes abuse and fraud."

So said the Principal Officer of the Government Employees Medical Scheme (GEMS), Dr Guni Goolab, in his closing address at the Scheme's annual conference held in Cape Town 15 - 16 August 2013, which explored the subject of fraud and abuse in the medical schemes industry.

"It has been estimated that losses due to fraud in South Africa are in the region of R4,1 billion. This is much too high a price to pay, particularly for a fledgling economy such as ours."

Dr Goolab observed that fraud artificially inflates healthcare costs. The higher the cost of fraud the less there is available to spend on the healthcare needs of members, he said.

Dr Goolab pointed out that members of medical schemes have the right to know what is happening to their contribution fees and what is being done to stem the unwelcome tide of medical schemes abuse and fraud. "We need to engage members fully in our quest to diminish this scourge. But first and foremost, we need to understand the true extent of the problem. That is why something tangible needs to be put in place at industry level to record and report actual losses as a result of fraudulent activity."

"At present one of the greatest challenges in the industry is a lack of cooperation and involvement on the part of members," noted Dr Goolab. "Member education programmes and active engagement can go a long way towards improving this situation. Members must fully grasp what is at stake and they need to understand the criminality of fraud and medical schemes abuse."

Dr Goolab said that it had been pointed out in the conference that members still perceive medical schemes fraud as a victimless crime. They mistakenly believe that by perpetrating this crime no real harm is being done.

Peter Goss of PricewaterhouseCoopers (PWC) said at the conference that "a game changer" was needed when it came to medical schemes fraud. He said that fraud was an act of depriving people of a fundamental human right. One way of putting it to an end is to make it an obligation to report medical schemes fraud by rendering it a statutory offence.

Lynette Swanepoel of Board of Healthcare Funders (BHF) said that medical schemes needed to start collaborating and working faster, smarter and better to combat fraud. This could well be the game changer that is needed.

Dr Goolab said that from a GEMS perspective he was filled with considerable pride to hear how the Scheme had in many ways taken the lead in the fight against fraud within the industry. This was not because the Scheme had bigger problems with fraud than other medical schemes but because it cares about its members and the sustainability of the scheme.

"It is good to see GEMS working hand in glove with the SAPS, the Hawks and SARS," he added. "I believe few medical schemes can lay claim to the fact that they have actively engaged, trained and collaborated with law enforcement agencies to the extent and with the excellent results that GEMS has done. The work done by the Scheme is laudable and a solid foundation from which to launch a fully fledged industry war against fraud."

Dr Goolab said that the conference had covered all of the aspects of fraud and dishonesty within the medical schemes industry including the types of abuses that were being conducted, the costs associated with fraud, methods of preventing and mitigating the problem, legal and ethical considerations and international aspects. "I think that this meeting has been highly successful and the industry can use it as a solid starting point in its efforts to tackle this menace. GEMS Contracts and Operations Executive Bella Mfenyana's so aptly quoted Albert Einstein earlier in the conference: "The world is a dangerous place not because of those who do evil, but because of those who look on and do nothing."