Inside the great R15bn medical aid swindle
Doctors, patients, brokers and syndicates are creaming off an estimated 10% of the more than R150-billion paid out every year
The most common fraud involved false claims. One of the interviewees told the researchers: “They are claiming for certain procedures not performed.”
Then came irregular billing. “Service providers ... claim for a code of a higher value than the actual service or treatment provided,” said Legotlo and Mutezo.
“Service providers [also] billed for excessive time. [And they] sometimes supply members with cheap products but claim for more expensive ones.”
Other frauds involved service providers claiming from medical aids for treatment which a patient had already paid for, and billing for products covered by the medical aid but supplying products that were excluded from the cover provided by the policy.
“Optometrists are supplying sunglasses and claiming for spectacles,” said an interviewee. “Each provider has a different type of fraud in his field.”