Health Care Fraud Costs YOU Money!

    Health care fraud costs medical aid members an additional R192 to R410 a month.

    It is severely hampering efforts to provide affordable and quality health care to all South Africans.

    Fraud constitutes between 7% and 15% of health plan claims lodged in South Africa.

    It’s the estimate by the Healthcare Forensic Management Unit.

    According to Bonitas Medical Fund. The prevalence of health care fraud is on the increase and involves collusion by medical aid members with health care providers.

    Health Care FraudDr Bobby Ramasia. Bonitas chief executive officer, says that fraud is one of the most common crimes in South Africa today.

    He says that it is also one of the most complicated forms of fraud, making it harder to detect, monitor and prevent.

    Health care fraud

    Apparently, health care fraud occurs along the entire chain of delivery, involving employees, administrators, medical scheme members and providers of healthcare services.

    Dr Ramasia points out that health plan fraud is seriously hampering efforts to provide affordable and quality health care to all South Africans.

    Fraud, abuse and wastage are costing the South African medical aid industry in the region of between R9 billion and R19 billion every year.

    Dr Ramasia says fraud is costing Bonitas more than R260 million annually. Even though the company has managed to reduce losses to about 3% of its annual turnover.

    He says the increase in the number of health care fraud cases is due to the sophisticated methods employed by perpetrators.

    It is, therefore, necessary, according to Ramasia, that methods used to fight fraud must keep pace with the times.

    For this reason, Bonitas has partnered with Helios IT Solutions and international analytics software company FICO.

    The company estimates a potential saving of 8.7% on claims processed in the future.

    The FICO solution will monitor irregular claiming patterns, leading to early warning signs and the implementation of the necessary action.

    Once a fraudulent claim is detected, forensic specialists are appointed to investigate and take appropriate steps.

    So Dr Ramasia says if perpetrators know they will face severe consequences. For their illegal activities, they will be less likely to commit fraud.

     

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