Some of the fraudulent and wasteful activities by medical scheme members involve the following:
Collusion between members and healthcare providers in order to get illegal financial gain from a medical aid scheme.
Cash back claims when members are admitted to hospital for procedures that could have been avoided in order to claim through hospital insurance products.
Non-disclosure of prior ailments is the most common fraud reason cited. This occurs when a member fails to inform the medical scheme about previous health conditions.
Card farming occurs when members share their medical scheme benefits with non-members. This type of fraud is reported to be prevalent with female members, who cover only one child on the medical scheme, but all the children then share the benefits of that one child who is covered. Fraud, waste and abuse have cost medical schemes billions of Rands each year, and are contributory to price increases.
The Scheme’s fraud line is managed by an independent team that ensures that members reporting fraud remain anonymous. The location of the secure call centre is not made public to ensure the protection of caller records. All callers remain anonymous, unless they choose to reveal their identities. If you know of any fraud that is taking place or being planned, put an immediate stop to it by calling the anonymous, 24-hour, toll free fraud line on 0800 200 564 or email tip-offs to firstname.lastname@example.org.
IF YOU ARE FOUND TO HAVE COMMITTED FRAUD, THE SCHEME MAY:
- Cancel your membership
- Insist that you pay back any amounts the Scheme had previously paid relating to the fraudulent matter
- Open a criminal case against you
- Report you to your employer