An Unhealthy Cycle

Defrauding medical aids is counter-productive – and against the law

There are many reasons why you shouldn’t defraud your medical aid. Chief among them is that it is against the law. But perhaps another important but less obvious reason is this: to defraud your medical aid is to defraud yourself.

It is estimated that the economy loses a massive R55.2 billion annually to sick leave, according to Adcorp Holdings’  employment index. While the majority of this figure may well be attributable to real sick leave, it does raise serious concerns around fraudulent claims in the medical field. It also causes a number of major disadvantages for scheme members, key among them that fraud pushes medical aid fees higher.

Medical aid schemes work out the benefits for each option offered and have these options priced by an actuary every financial year. Should payment of benefits exceed these calculations, resulting in a loss for a scheme, this impacts on the percentage increase of the membership fees for the next year. So, even if you are not guilty of abuse, you pay.

According to Dr Elsabé Conradie, spokesperson for the  Council for Medical Schemes (CMS),  medical schemes have mechanisms or investigation units to deal with criminal issues, including the authority to lay criminal charges against fraudulent parties, whether they are practitioners or members.

In the eye of the medical fraud storm is the Health Professions Council of SA (HPCSA). The body is facing criticism from medical aid schemes, who feel that doctors involved in fraud have escaped with slaps on the wrist, which will not act as a deterrent to others contemplating similar crimes. Alternative strategies suggested include suspension from practise.

They are not alone. The  Board of Healthcare Funders (BHF), which represents medical aid schemes, also feels the council is ‘losing the war’ on medical aid fraud.