State medical aid uncovers at least R10m in suspect claims on hospital cash-back plans
The Government Employees Medical Scheme (GEMS) believes it has lost at least R10m in fraudulent claims for hospital stays. GEMS had uncovered evidence that pointed to healthcare practitioners and members as the culprits, Principal officer Dr Guni Goolab said on Tuesday. The evidence came to light in a widespread review of claims submitted by a variety of service providers, including a number of in-hospital claims. Goolab said GEMS had discovered a number of instances where claims were irregular or questionable. In some of the cases investigated, patients had not undergone any significant pathology or radiology tests following admission to hospital, even in instances where they were reportedly seriously ill. Hospital cash-back plans are intended to help members pay medical bills not covered by medical aid, or to subsidise income lost during a hospital stay. The investigation revealed that GEMS was being used to fund medical conditions that could either have been treated within a shor...
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