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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.”

The architects of National Health Insurance can learn a lot from the numerous ways medical aids are defrauded, say two Unisa researchers. Tsholofelo Legotlo and Ashley Mutezo interviewed 15 employees involved with fraud management at one of the biggest medical aid administrators and heard how doctors, patients, brokers and syndicates are creaming off an estimated 10% of the more than R150-billion paid out every year. “As SA plans to implement the National Health Insurance, policymakers should take cognisance of the fraud perpetrated against medical schemes and proactively put mitigating strategies in place,” they wrote in the South African Medical Journal.Legotlo and Mutezo, from Unisa’s finance department, said medical practitioners had dreamed up the most ways of defrauding medical aids — backing a 2015 study which found that 52% of ethical transgressions punished by the Health Professions Council were for fraud. The most common fraud involved false claims. One of the interviewees...

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