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Fraudulent activities, waste and abuse have forced the industry to be vigilant By Lungi Nyathi

A Gauteng doctor was recently sentenced to five years' imprisonment after being convicted of 259 counts of medical aid fraud. He used a "runner" who provided details of medical aid members to him and then billed the scheme fraudulently. The scheme identified a sharp spike in his claims and some members contacted the scheme complaining about claims submitted on their accounts without their knowledge and no service having been rendered to them.

In another recent incident, independent pharmacies were found to be colluding with members by claiming from schemes and sharing the money. We discovered this when instead of sending us the supplier invoices we requested, the pharmacy sent the list by mistake. Here are other examples of fraud, waste and abuse of medical aid funds: a doctor billed for seeing more than so patients in a single day some were dead, a doctor billed R4m for hearing aids. This may translate to seeing more than 20,000 patients, a dentist claimed for teeth that had long been extracted, a physiotherapist billed for 100 appointments in one day, a doctor who saw patients in Durban, Bloemfontein and Pretoria on the same day.

The above examples confirm that we are under siege, and put to bed allegations by Sowetan columnist Palesa Lebitse in her July 2 article head lined: "Supposed watchdog lets medical aid schemes go rogue with impunity." According to the Board of Healthcare Funders, at least 10% to15% of all medical aid claims are fraudulent, a substantial expense in a Ri5obn industry. According to the Association of Certified Fraud Examiners, the world's largest anti-fraud organisation, the io most common healthcare provider fraud schemes are: billing for services not rendered, billing for a non covered service as a covered service, misrepresenting dates of service, misrepresenting locations of service, misrepresenting provider of service, incorrect reporting of diagnoses or procedures, over utilisation of services, corruption kickbacks and bribery , false issuance of prescription drugs. The total fraud costs in the SA private healthcare system is estimated at R22bn each year. The above figure confirms that fraud, waste and abuse are a serious problem and a tragic loss of scarce resources earmarked to provide healthcare to those most in need. Have medical aid companies gone rogue? Not at all. We honour claims in good faith and more than 98°° of the R4Obn in claims we administer annually are paid immediately. To identify fraudulent activities, we use a predictive analytics system to identify claiming behaviour.

We have the right to retrospectively review claims due to anomalous patterns that require further investigation. One way to verify that valid services were indeed rendered, has been to ask a practitioner to provide patient files as proof that treatment did actually occur. Patients have consented to share their records and other clinical information with the medical scheme in their membership application form.

We do not "bully" healthcare providers; all our correspondence is done in writing and we only have meetings with them at their request. In such engage ments, we encourage the medical practitioner to have legal representation. We can only withhold payment pending finalisation of the audit. We try to finalise all cases within 30 days but this is subject to receiving the full cooperation of the service provider who is under audit.

Accusations that we use hidden spy cameras or fake membership cards to entrap a suspect are false. Our company does perform unannounced physical inspections without appointment, to avoid window dressing by the service provider. In 2018, we opened 19 criminal cases. We also reported 94 providers to the Health Professions Council of South Africa for unethical conduct. We cannot continue to honour claims when their validity is in question. Dr Nyathi is executive director for health management at AfroCentric Group, owners of Medscheme

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