Millions lost to fraud which should have been used to pay valid claims
Industry experts say that fraud in the medical scheme industry costs members anything between R10 billion and R20 billion per year, making fraud, waste and abuse one of the main drivers of healthcare inflation.
Medical schemes are non-profit organisations and these amounts should be used to pay honest members’ medical bills. Fraudulent behaviour of providers, and in some instances members, is basically stealing money out of your pocket. Discovery Health, our administrator, recovered R405 million in 2016 and R568 million in 2017 for the schemes it administers. Discovery Health works with a team of over 100 analysts and investigators, as well as forensic software systems with sophisticated algorithms in place to identify unusual claims patterns and to uncover fraud. All of these measures are necessary but costly – paid for in part by members’ scheme contributions.
What are your responsibilities as a member?
- Ensure that your provider only bills for services rendered and that he/she only prescribes necessary and valid medication
- Check your statements to ensure that all claims and services you or your dependants received are correct
- Report any corruption, kickbacks and bribery you come across
- Only submit valid claims for registered dependants on your membership
- Keep your membership details in a safe place, whether they are printed or online
- If there are any irregular or unknown transactions on your membership, call 0860 222 633 to find out what they are for
Blow the whistle!
Protect your Scheme and its benefits! If you come across potential fraud, waste or abuse please call our independent ethics line on 0860 004 500 and report any form of unethical practices in an anonymous and secure manner. You can even report fraud on other schemes. If members and providers abuse another scheme today, they could use the same tactics on AMS tomorrow.
The consequences for fraudsters
Fraud will cost the individual his or her membership and employment. Fraud is a criminal offence. In severe cases, providers that have committed fraud have already been sentenced to jail time.