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AFROCENTRIC: TAKING ON THE HEALTHCARE'S TRIPLE THREAT

It starts with you: Taking on healthcare fraud, waste and abuse. Healthcare fraud is not a victimless crime — you are the victim. If you have medical aid, you are a victim of healthcare fraud!

Every false or inflated claim submitted to your medical aid contributes to the R80 million lost daily to fraud, waste and abuse (FWA) in the South African healthcare system. FWA costs the industry billions every year, an amount that has to be covered by members through higher medical aid premiums and out-of-pocket expenses. FWA also reduces the resources available for essential treatments for patients who need them, and it often leads to unnecessary treatments, which can harm patients and reduce the overall quality of their care.

Fight for what is right

General Manager of Healthcare Fraud and Abuse at the Afrocentric Group, Gerda Strydom, recognises fraud as a major global problem, but emphasises that ”never does it feel more personal than when that fraud is committed at the expense of the well—being and good health of our own people";

Medscheme, a subsidiary of the AfroCentric Group, is the countw’s largest provider of health risk management services. Medscheme has over four million lives under its care and manages 15 medical schemes.

Medscheme is serious about protecting the funds of medical schemes it administers and ensuring sustainable healthcare for all members. Therefore, it comprehensively investigates potential fraud, waste, and abuse cases.

"Payment of irregular claims reduces the pool of funds that should be utilised for medically necessary healthcare services. Medical aid contributions are already unaffordable for most South Africans, so FWA negatively affects the sustainability and affordability of the healthcare system as a whole,” Strydom explains.

Fighting back

Given the challenges they face, medical schemes have adopted an increasingly robust approach to dealing with FWA. “Medical Schemes have a duty to protect their members’ funds,” says Strydom.

"We process over 12.5 million claim lines and pay more than 40,000 healthcare practitioners every month, so it is critical to have a comprehensive fraud risk management programme in place,” she says. The programme includes fraud prevention, detection, investigation, risk mitigation, and reporting.

By following up on tip-offs and using advanced detection tools, Medscheme Forensics, on average, opens 300 cases for further investigation every month. "Over the past five years, we have recovered R736 million for our client schemes. We estimate that our efforts reduced wrongful billing behaviour by R3.7 billion with many more millions saved through our proactive fraud control activities," reports Strydom.

Don’t be tempted

Difficult economic conditions are known to lead to increased crime levels, including healthcare fraud. So, while it may be tempting to rationalise using your medical aid in an illicit way, bear in mind that you will still end up paying for it.

Furthermore, medical aid companies are investing more and more in digital technologies to protect their members. Tools such as advanced data analysis, machine learning, predictive analytics and artificial intelligence are increasingly being used to close the net on FWA. If you get caught benefitting irregularly from your medical aid, the consequences can be severe - including facing criminal charges and termination of membership.

Take responsibility

Fraud, waste, and abuse contribute to higher healthcare expenses and do not deliver any value in terms of improved patient care. To counter this, Strydom calls on medical aid members to play a proactive role in preventing FWA.

Steps you can take

• Understand your medical aid benefits and engage your healthcare provider to ensure that you know what will be claimed from the scheme.
• Check your claim statements carefully and ensure you received the services your service provider claimed for.
• Make sure your membership card and number are protected.
• Don't accept cash from a service provider in exchange for a medical aid claim.
• Report suspicious behaviour.