Medical aid fraud has become somewhat of a hot topic in recent months after The Times newspaper reported on the seriousness of the matter in the healthcare industry. However, it is not a new problem. Medical aid fraud has been going on for decades and both patients and practitioners are responsible for this illegal activity. In fact patients often collude with practitioners to defraud medical aids without thinking of the repercussions. For medical aid members this translates into rising monthly contributions with less benefits. For doctors and other healthcare providers, it is leading to a decline in payouts and less profitable private practice. Both doctors and patients need to realise that medical aid fraud is costing the, not just money – it could even lead to jail time.

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Popular Fraud Trends

There is no denying that criminals are creative and this includes patients and practitioners who indulge in medical aid fraud. There have been numerous media reports in recent years, including on TV and in newspapers, about scams utilised to defraud medical aids. While both patients and doctors are aware of their wrongdoing, at times some medical aid members are ignorant and do not realise the serious of their illegal activities. Unfortunately ignorance is not going to spare any person from facing the full might of the law when they are caught. Here are some of the more common medical aid fraud trends seen in South Africa.

  • Pharmacists billing for medicines but allowing patients to buy vitamin supplements and non-medical items instead.
  • Healthcare practitioners giving patients a “cut” for billing their medical aid for treatments that are never done.
  • Practitioners selling non-medical products to patients and billing their medical aid.
  • Practitioners billing for items and treatments that are never used or done.
  • Medical aid members colluding with healthcare professionals to admit them in hospital in order to receive payouts from hospital cash back plans.

It is important to note that medical aid fraud is not isolated to a specific discipline in the medical industry. Similarly medical aid fraud is a problem faced by all schemes.

Member Misconceptions

As a medical aid member, the responsibility lies with you to report any fraudulent activity that may have been conducted by a practitioner when your medical aid is billed. Schemes are unable to differentiate between legitimate and fraudulent billing on the part of practitioners if medical aid members do not inform them accordingly. The money paid out by your medical aid does not belong to the member. Medical aids work by pooling the contributions of all members on the scheme and paying out for services rendered to members who need legitimate medical care. By fraudulent extracting money from your medical aid, you are committing fraud as you are using scheme resources for non-medical purposes.

Medical aid premiums have been increasing year on year. And benefits often do not match the increase in contributions. It is not your medical aid that is getting ‘richer’ as some members believe. Medical schemes in South Africa are battling to deal with rising healthcare costs while covering patients to a degree that allows them to get the best possible private health care. Fraudulent activities and overusing medical aid benefits are some of the reasons that South African members are buckling under the ever increasing premiums and lesser benefits.

However, honesty on the part of patients and practitioners could in fact spare this trend by medical aids. Fraud is not the only reasons for the strain that medical aids are currently experiencing but it is definitely one of the major contributing factors. Think before you use your medical aid – do you really need the service or medication? Consider how you are disadvantaging yourself by overusing your medical aid or colluding with practitioners to defraud the scheme. Do not be misled by any person, whether a medical professional, friend, family member or colleague, to indulge in any activity that is fraudulent. While you may be putting a few rands in your pocket today, you will pay a heavy price in years to come.

Medical Aid Fraud Affecting Doctors And Patients
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