Add your voice to the fight against medical scheme abuse

Help us tackle the scourge of fraud 

Wednesday, 19 November 2014

Have you ever considered the impact of fraud on your pocket? Fraud has gained a tremendous foothold in the private healthcare industry and is costing medical schemes and their members dearly.

To begin with, fraud artificially inflates healthcare costs. The higher the cost of fraud, the less there is available to spend on the healthcare needs of members.

At GEMS we believe 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 scheme abuse and fraud. That is why we are in constant communication with our members in our quest to diminish the impact of fraud on the Scheme and its members.

Unfortunately many members still perceive medical scheme fraud as a victimless crime. They mistakenly believe that by perpetrating this crime no real harm is being done. Together we need to change this perception as it is important for members to fully grasp what is at stake.

People may think it is not that serious to defraud a medical scheme, but it is a criminal offence. GEMS will take action against anyone who attempts to defraud the Scheme including members, healthcare professionals or any other stakeholders.

Medical scheme fraud includes a range of dishonest activities. At times it may involve the theft and use of a member's medical scheme card, however sometimes scheme members themselves get involved in illegal activities. A member may, for example, allow a friend to use his or her medical scheme card to obtain free benefits. Cases have also been reported in which medical scheme members have colluded with medical professionals in order to submit false claims.

Sometimes members involve themselves in illegal activities without even being aware that they are doing so. If you are not sure whether you are engaging in illegal activities then check with your scheme before acting. Get to know your scheme rules and make sure that you use your benefits correctly.

Fraud does not just negatively affect medical schemes; it impacts their members as well, leading to reduced reserves and sometimes even increased member contributions. Fraudsters steal medical scheme members' benefits and profit at the expense of other members.

GEMS has always taken the lead in the fight against fraud within the industry. This is not because the Scheme had bigger problems with fraud than other medical schemes but because we care about our members and the sustainability of the Scheme.

Not only does GEMS work closely with the SAPS, the Hawks and SARS, but we have also actively engaged, trained and collaborated with law enforcement agencies and in the process we have achieved excellent results.

We have also introduced a number of member education programmes and with the assistance of active and consistent communication we have made considerable inroads in keeping fraud under control within GEMS.

The work done by the Scheme has set a solid foundation in place from which the greater healthcare industry can wage a fully fledged war against fraud at every level.

Contact the GEMS Fraud Zone

If you know of any fraud taking place or being planned, put an immediate stop to it by calling the anonymous 24-hour toll-free GEMS Fraud Line on 0800 21 22 02.     
You can also send an email to [email protected] or send a fax to 086 726 1681. Information can also be mailed to: The Fraud Services Manager, PO Box 21076, Valhalla 0137