FRAUDLINE

Although it is not always easy to pick up on fraudulent transactions due to the various forms that they take, Resolution Health Medical Scheme does have certain daily and monthly processes in place in order to identify and eliminate fraud.

In addition, some medical practitioners have also been found guilty of fraud, a source of fraud which Resolution Health has dealt with through the establishment of our extremely vigilant forensics department.

Market research shows that between 10% and 15% percent of all medical scheme claims in South Africa are fraudulent

According to the report of the Registrar of Medical Schemes, the contributions to all medical schemes in South Africa for 2000 were R30 894 billion. If this is broken down between the members, one can come to the conclusion that each primary medical scheme member in the country loses between R100 and R150 per month to fraud.

Although some members of a scheme work in conjunction with service providers to commit fraud, others do so privately. They will apply to a medical scheme, but will not disclose all their ailments or that they are to receive major surgery in the near future. Annually, Resolution Health Medical Scheme identifies members for non-disclosure for major operations, with the total cost well in excess of R1 million. These non-disclosures were identified through strict management, and in most cases these members were suspended for fraud.

There is no excuse for fraud. It breaches the trust relationships between medical schemes and service providers, as well as affecting the pocket of the public. If convicted, we feel that offenders sentences should be harsh.

In addition to the public, some medical practitioners have also been guilty of fraud. Thanks to our vigilant forensics department, these misdemeanors are often detected. Fraud in this sector usually involves slightly altering information on invoices and resubmitting them. Many of these would-be fraudsters have subsequently been prosecuted.

If you are aware of any fraudulent practices, contact us on 011 791 1227