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Monday, 4 March 2019
Paul Midlane, General manager
of healthcare forensics at Medscheme

Medscheme healthcare forensics practitioner took this photo of a surgery, which was claiming R1m for medication despite the fact that the 'surgery' was not operating. Medical practitioners heard astonishing stories of fake medical aid claims at a summit discussing fraud in the industry, which started in Johannesburg on Thursday. Paul Midlane, general manager of healthcare forensics at Medscheme, listed several case studies, including a doctor claiming to work for 491 hours a day. Other examples included a medication claim for R1m from a surgery operating from a derelict building, a cardiologist who performed 856 angiograms out of 1,748 patients in one year (amounting to a R10m claim); an orthopaedic surgeon who got R1.6m for a claim that normally costs R5,182 and a biopsy that cost R44,800 when it should cost R1,450.

The inaugural Fraud, Waste and Abuse Summit was held at the Sandton Convention Centre and aimed to address what medical schemes and medical practitioners believed was an unclear industry charter on fraud. Among the black and grey suits sat members of the Council for Medical Schemes (CMS), the Healthcare Funders Association, Special Investigations Unit (SIU), the SA Fraud Prevention Service, department of health, Section 27, SA Medical Association and various heads of medical schemes. The Health Professions Council of SA did not attend.

Advocate Andy Mothibi, head of the SIU, said about 15% of all medical claims fell into the fraud, waste or abuse category, a number the CMS predicts could be costing the healthcare industry as much as R28bn a year. “The issue is bigger than what we thought and we can’t just blacklist those that are in contravention or we will completely cripple the industry,” he said. Sipho Kabane, the chief executive registrar for CMS, put the number in context. “The entire health budget for the Northern Cape is R24bn, so if we could save the private sector the scourge, then we could fund the health of an entire province for a year. “We can’t ignore the crisis in the private sector because it drives medical scheme prices up. When this happens, some of the 8.8 million people on private schemes must then trickle down to state-funded health. This places strain on the already strained state health pool,” Kabane said. As an example, Mothibi said the SIU, together with the National Prosecuting Authority and the Hawks, arrested a lawyer at the beginning of February who put in six medical claims for more than R90m. “When we checked the files, all were fraudulent. The lawyer attempted to bribe one of our officials and was arrested. When he was out on bail, he sent further claims. We checked those too – they were also fraudulent. It is never-ending, and we see the same faces doing it over again.” When we checked the files, all were fraudulent. It is never-ending, and we see the same faces doing it over again. Andy Mothibi, SIU head Mothibi said the problem was that the SA Police Service was not aware of the laws around medical fraud, “so they always needed to be educated”.

“Then if there ever was a conviction, someone defrauding the schemes for millions could get as little as a R10,000 fine – suspended for a few months,” he said. Currently, only 10% of claims are investigated, and of those claims, only 1.33% of funds are recovered, according to Marius Smit, head of investigations at Discovery Health, who has spent 20 years in the healthcare forensics industry. The two-day conference will try to promulgate and clarify section 59 of the Medical Schemes Act, which says any payments given where the entities were not entitled to money must be returned to the scheme.

Currently fraudulent contraventions of this act must be tested by the law, meaning fraudulent practices must be tried in court. But there is contention within the industry over whether waste and abuse should also be tried by the court. The summit will also be used to draft definitions for the charter to make it clearer. Get the Times Select app or daily email newsletter.

Journalist Alex Patrick

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