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Clampdown on healthcare fraud

Jul 26 2012 11:04

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Cape Town – The healthcare sector is losing between R4bn and R13bn every year through fraud, abuse and unethical behaviour, according to Liberty Medical Scheme (LMS) executive principal officer Andrew Edwards.

As many South Africans find it increasingly difficult to make ends meet, instances of fraud and abuse on all sides of the spectrum – from members, healthcare providers and employees to intermediaries, administrators and trustees – appear to be on the increase.

"The ultimate cost of healthcare fraud is felt the hardest by the scheme members, who pay the monthly contributions towards their medical cover," Edwards said.

According to him it is paramount for the healthcare sector to stringently monitor any suspicious conduct and claim, and act speedily and decisively to prevent the unnecessary loss of funds.

The most recent KPMG anti-fraud survey showed that member claims represented a relatively small amount of R67.3m out of a claim value of R145bn over the three-year period from 2007 to 2009.

Non-disclosure of prior ailments was the most common reason cited for member fraud.

The survey also found that service provider fraud was increasing, with code manipulation the most common type investigated. This was followed by services not rendered.

According to Edwards, LMS is taking a zero tolerance approach to fraud and abuse.

"A dedicated team of forensic specialists monitor, detect and investigate any instances of fraud or abuse at LMS and the team is strengthened by other clinical specialists in the business.

"Private healthcare fraud and abuse is a national problem affecting all of us, either directly or indirectly. This loss leads to increased costs for all stakeholders involved, everyone from funders and providers to medical scheme members.
 
"The ultimate cost of healthcare fraud, however, is felt the hardest by the scheme members, who pay the monthly contributions towards their medical cover," he said.

"By vigilantly monitoring fraudulent behaviour and acting swiftly to bring culprits to book, LMS has managed to recoup significant amounts of money, to the benefit of our members," Edwards said.
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