How medical aid fraud affects you – Part 2

medical aid fraud

Medical aid fraud can have many different faces and affects every member

Refer to our previous article (Part 1) on this topic.  Now read more about this white-collar crime and the numerous ways in which this fraud is perpetrated.

The following are just some examples of how medical aid fraud can present itself:

Fraud committed by members

  • Submitting false or altered invoices or colluding with a service provider to submit false claims.  Claims paid are then for the benefit of the member or are shared with the service provider.
  • Allowing non-members to use his/her membership to obtain treatment.  This is usually done by collaborating with a healthcare provider to use their membership details to claim benefits.
  • When a member conspires with his/her treating doctor to perform surgery that is normally excluded, such as cosmetic surgery, to submit a false claim for a different approved procedure.
  • Dual membership, where a member belongs to 2 medical schemes at the same time and where claims are submitted to both schemes.

Fraud committed by service providers

  •  ICD-10 codes can be manipulated so that tariff codes with a higher monetary value are billed or, the scheme can be billed for codes in respect of services not provided.
  • Hospitals can bill additional theatre time (who will ever know, as the patient is “out” and the medical scheme is not present).
  • Hospitals practicing merchandise substitution, i.e. where they charge the scheme for an oxygen tank while only a nebuliser was provided.
  • Service providers can charge the maximum benefit allowed in terms of his patient’s plan option, i.e. charging the scheme R45 000 for the prosthesis used in a knee replacement, while the actual prosthesis used only costed R22 000.
  • Service providers claiming for non-covered benefits under ICD-10 codes that are covered in terms of the scheme benefits. • Service providers can offer their patients money in exchange for submitting a claim to their medical aid.
  • Pharmacists can claim for original, more expensive medicine while dispensing a cheaper generic alternative, or claim for more medicine than what was in fact dispensed to the patient.
  • Pharmacists can submit medicine claims, but actually supply household items to members.

How can you prevent fraud?

Always analyse your claims statements carefully and check that you have in fact received the services / products claimed for by your healthcare provider.  Never accept money in exchange for a claim to your medical aid.  Medical aid cards must always be kept in a safe place and lastly, always report suspicious behavior to your medical scheme.

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