“Although likely to be less than the 2019 estimate of R22bn, due to a reduction in consultations and utilisation in general during Covid-19, fraud, waste and abuse (FWA) is still a huge problem,” says Dr Hleli Nhlapo, chairperson of the HFMU.
“This is not only on isolated identities, but those of doctors either dead or overseas or across provinces, being used to submit significant volumes of false claims. Some cases have also included theft of members’ identities,” says Nhlapo.
From one or two isolated cases a year, the HFMU has reported that there have been a lot more during the last year. “It is not individual providers any more, for example just one pharmacy committing fraud, but now it is syndicates – it’s organised crime,” notes Nhlapo.
“We have seen a group of organised individuals in some instances stealing 13 different doctors’ details, and then submitting claims as though they originated from these specific practitioners,” he says.
“We need all medical schemes to utilise the HFMU as a resource to collaboratively tackle the challenges of fraud and abuse in healthcare, as it’s the only way we can get ahead of these criminal activities,”
“Although FWA losses are incurred by the medical schemes directly, members ultimately bear the impact, through unavoidable increases in their scheme contributions,” says Nhlapo.
He notes that, if this loss could be taken away, it could lead to as much as a 10% reduction in members’ monthly contributions.
“Then, obviously, if there were no losses, there would also be a better opportunity for enhancements in the benefits available to beneficiaries,” he says.
