Destructive collusion between healthcare providers and members

There is an increasing number of fraud cases reported where it is apparent that some members work together with healthcare providers to defraud the Scheme. Did you know that it is estimated that about R13 billion in yearly contributions paid by South Africa's eight million medically insured people is possibly lost to fraud and wastage?
According to the medical schemes Ombudsman report released in March 2012, the highest number of fraud cases are for claims charged for services not rendered. As a member, you need to be vigilant and constantly check if the claims statement sent to you on a monthly basis is accurate.
The most common cases of fraud where members collude with service providers are:

• Fictitious claims - healthcare providers give members cash and then falsely claim for services;
• Multiple claims - when healthcare providers falsely submit several claims for one service event;
• Claim alterations - when healthcare providers change claims in order to be paid larger amounts for services reported to have been rendered. The healthcare providers then pays the member a portion of the amount received;
• Non-medical items at pharmacies - Some pharmacists allow members to buy non-medical items from their personal medical savings accounts (PMSA) and they then submit claims for various types of medicine; and
• Healthcare providers who treat a member's family or friend (not a registered dependant) and claim from their medical scheme under a registered beneficiary.

There are harsh consequences for persons convicted for fraud. As a member of the Scheme, you need to protect what is yours! Report fraud 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 a fax to 086 726 1681 or post your anonymous tipoff to The Fraud Services Manager, PO Box 21076, Valhalla, 0137.