Medical aid fraud: be part of the solution

Healthcare hijacked

Imagine a portion of your monthly medical aid premiums end up lining the pockets of criminals instead of being invested in your and your clients’ healthcare. Unfortunately, this is the harsh reality of medical aid fraud, waste, and abuse (FWA) that costs the healthcare system in South Africa an estimated R22 billion to R28 billion annually.

FWA encompasses a range of activities that siphon money away from medical care, ultimately harming everyone involved. Fraud involves intentional deception, such as submitting false claims or billing for unnecessary services. Waste refers to inefficient practices that increase costs without enhancing care, while abuse involves the misuse of services for personal gain.

The consequences of FWA are far-reaching:

• It drives up medical aid premiums, making healthcare less affordable for everyone.
• It forces schemes to allocate resources to fighting fraud instead of improving patient care, which reduces available benefits and value-added services.
• Ultimately, it erodes the sustainability of and trust in the entire healthcare system.

Non-disclosure

Non-disclosure (failing to disclose pre-existing conditions) is a common FWA practice. The most common instances of non-disclosure to be on the lookout for are:

Clients should disclose all relevant information about their own and their dependants’ health status and history, even if they received no treatment during the past 12 months.

Medihelp manages risk by investigating requests for authorisation, specialist referrals, or pregnancy benefits received during the first year of membership. If we discover that the client did not declare the condition, payment for treatment will be denied, leaving clients financially burdened. It will also lead to the cancellation of their membership.

Damage to trust and reputation

Medical aid advisers are responsible for helping their clients navigate the complexities of the healthcare system. However, when a client engages in fraudulent behaviour, such as failing to disclose pre-existing conditions, it can reflect poorly on the adviser’s expertise, judgment, and reputation. The resulting investigations, legal battles, and harm to business can also have a negative impact on overall well-being.

Preventing fraud: the adviser’s role

Advisers can help prevent fraud, particularly non-disclosure of pre-existing or newly diagnosed conditions, by following these tips:

1. Educate and inform



Clearly explain the importance of accurate information and the risks of non-disclosure.

2. Ask detailed questions



Discuss past and present medical conditions with clients. For example:

• Ask about daily vitamins. Could they indicate an underlying condition like iron deficiency?
• Was your client previously diagnosed with a high-risk condition but then stopped taking their medication? This can result in a higher risk for the scheme than a client who takes their medicine every day.
• After being diagnosed with a chronic condition, did your client adopt a healthier lifestyle? They still need to declare the condition.
• Was your client diagnosed with a chronic condition (for example, asthma) but hasn’t required any medication for a few years (for example, an inhaler)? It must still be declared.
• If your client buys over-the-counter medication to treat a chronic condition, they must declare the condition.
• Ask your clients if they are planning a family, suspect a pregnancy, or anticipate a pregnancy.


3. Review applications carefully



Scrutinise applications for inconsistencies and omissions. If your client answers "Yes" to any of the questions of the medical questionnaire in the application form, Medihelp will require details of the date of last consultation, diagnosis, and/or treatment.

4. Guide through disclosure



Assist clients in updating their records promptly if conditions arise after application.

5. Seek clarification from Medihelp



Ask your Business Development Consultant to explain Medihelp’s underwriting model and grid. Familiarise yourself with Medihelp’s specific policies and procedures regarding non-disclosure and fraud reporting.

6. Beyond non-disclosure



Stay updated and educate clients on common fraud practices like over-servicing, false claims, and identity theft. Give them information on how to report suspected fraud anonymously.

7. Take a stand and report fraud

Report suspected non-disclosure or other fraudulent activity anonymously through:
• Email: fraud@medihelp.co.za
• Phone: Medihelp’s fraudline on 012 334 2428

Every tip is investigated by Medihelp’s Forensic Investigations team.

Building a trustworthy future together

Medihelp is committed to ethical practices and fosters an ethical culture by actively participating in initiatives like ethics surveys and membership  of The Ethics Institute of  South Africa. We call upon our advisers to join us in this fight against fraud, waste, and abuse and to help build a healthcare system we all can trust.