Collaboration needed to combat medical aid fraud
Fraud, waste, abuse, and irregular payments within the healthcare sector are slowly crippling the industry, said the Board of Healthcare Funders (BHF). At the recent BHF conference in Cape Town, delegates agreed that there is a deep need for increased collaboration between stakeholders throughout the healthcare industry and related investigative services to effectively tackle fraud and waste.
“Fraud represents a material threat to the affordability and sustainability of medical schemes and also for any future NHI initiatives,” said Gregory Pratt of Medscheme’s forensic unit.
He added that if something isn’t done soon the affordability of schemes will reach a tipping point that will place too much economic pressure on young and healthy members, causing that essential supporting element of the industry to leave schemes and potentially collapse the industry.
Among some of the reasons given for the increase in fraud and irregular pricing, Pratt pointed to practitioners having a sense of entitlement in charging inflated amounts around Prescribed Minimum Benefit (PMB) cases, the infiltration of organised crime syndicates into the healthcare industry because it presents a soft target, and a desire to meet certain lifestyle aspirations.
Special Investigating Unit (SIU) head Andy Mothibi highlighted the importance of establishing methods that will bring together all possible stakeholders within the healthcare sector in order to tackle the issue and accelerate investigations into practitioners facilitating corrupt activities, emphasising the role played by “whistleblowers” in the success of such investigations.
He highlighted that the SIU is looking to “whistleblowers” to continue providing information to the SIU in order to tackle fraud, waste and abuse.
Mothibi proposed that investigation and prosecution proposals should be referred directly to President Jacob Zuma for approval. From there the entire process would be enabled through direct collaboration with numerous agencies across the board, including the criminal justice agencies, constitutional and other public oversight bodies, including the Public Service Commission, Public Protector, Parliament’s standing committee on public accounts (Scopa), Independent Police Investigative Directorate (IPID), the Inspector-General of Intelligence (IGI) and The Competition Commission.
“Of importance is to ensure that anti-corruption efforts should create a system that can operate freely from political interference and can be supported by both public officials and citizens.”