Fraud is an intentional and unlawful misrepresentation which actually or potentially harms another party. In other words, someone intentionally lies to gain an illegal advantage and their victim (in this case, Medihelp and you, the Medihelp member) suffers a loss because of that lie.
How does medical scheme fraud affect me?
Unfortunately, fraud relating to medical schemes claims affects medical scheme members by leading to:
- Increases in your membership fees
- Reductions in your benefits.
Medical scheme members and medical practitioners can commit medical scheme fraud. Fraudulent activities on the part of members include:
- Omitting important information on their application forms, e.g. pre-existing medical conditions and previous medical scheme membership
- Allowing unregistered family members or friends to visit the doctor while they pretend to be a registered beneficiary
- Colluding with medical practitioners by accepting a bribe in return for allowing the medical practitioner to submit false claims to the medical scheme.
Fraudulent activities on the part of medical practitioners include:
- Submitting claims for the treatment of a beneficiary (or beneficiaries), whilst never actually having provided medical services to the patient(s)
- Submitting claims for services never rendered after bribing members to allow the medical practitioner to misuse a patient’s medical scheme membership
- Altering treatment dates on accounts where claims are rejected because these were received outside the submission period in order to qualify for benefits
- Over-servicing, that is the dispensing of unnecessary medication or conducting unnecessary tests
- Claiming for procedures which are allowed in terms of Medihelp’s Rules, but then performing an alternative procedure which isn’t covered. For example, performing a tummy tuck and then claiming for a hernia operation.
If we work together, we can stop medical schemes fraud! Here’s how Medihelp is tackling the challenge:
- We have a Forensic Investigations department dedicated to the investigation of allegations of fraud.
- Every rand which is saved or recovered by detecting or preventing fraud benefits you, the Medihelp member, by helping to keep medical inflation as low as possible.
Here’s what you can do to help. Report fraud by:
Your details, and any other information pertaining to you, will be treated confidentially. You can also choose to remain anonymous.