Healthcare Fraud Awareness and Member Assistance


As members of a medical aid, we all want to be able to access the necessary level of healthcare in a time of need, covered by the monthly contributions we pay.

It is an unfortunate reality that a significant number of healthcare professionals across many disciplines, have lost their moral compass and feel entitled to exploit our private healthcare system and unduly enrich themselves. This is despite the economic hardship felt by most members and their struggle to afford the ever-increasing medical scheme premiums. It also taints the hard-earned reputations of the majority of conscientious and caring practitioners whose main aim is to improve the health status of their patients.

Fraud and alternatively abusive claiming behaviour, eat into the limited reserves of a medical scheme and force schemes to tighten their control over the benefits that they provide. The funds lost through fraud must ultimately be paid by the membership base, instead of being made available to expand necessary healthcare amongst its covered families.

We can define fraud as the ‘intentional misrepresentation of the facts in order to illegally/ unethically obtain financial gain at the expense of someone else. In healthcare, this is most often done through performing unnecessary tests or procedures, claiming for services not rendered, tariff code manipulation or collusion between healthcare providers and our members. Some members may even ‘loan’ their membership card to a friend or relative, so that they may receive healthcare services. Another example of a fraudulent claim is where a member receives cash or other grocery items at a pharmacy, whilst medicines are claimed from the scheme.

Members must be vigilant when accessing healthcare services to ensure you are only billed for what was done and that you raise a query with the Scheme if there is any suspicion of undue claims being submitted on your membership number. This would include checking the medicine received at a pharmacy against the invoice you sign, making sure that all practitioners claiming whilst in hospital were actually seen in hospital and that those claims accurately reflect what was done.

Medscheme has implemented very advanced industry-leading analytical software in their forensics unit, in order to identify more accurately and more readily the abnormal claiming patterns received from healthcare providers. Each practice is compared to their peers and outliers are flagged for investigation. Where anomalies are identified and cannot be rationally explained by the provider, money will be recovered for the scheme. If the anomalies are serious, then the provider will be reported to the HPCSA or even the police. Members found to be colluding with practitioners may be removed from the scheme or a criminal case may be opened against them. Fraud will not be tolerated for the good of all members on our medical schemes.


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