• R300 million worth of fraudulent claims where detected by medical administrator Medscheme last week. 
  • It is estimated that between 5% to 20% of medical claims are fraudulent. 
  • Medscheme highlighted some of the most interesting instances possible fraud in the South African sector.  

Last year medical aid administrator Medscheme detected R300 million worth of fraudulent claims, it reported this week.

Estimates of fraud, waste and abuse in medical aid schemes in South Africa range from 5% to 20% of every claim lodged.

Business Insider South Africa spoke to Paul Midlane, the general manager of healthcare forensics at Medscheme, to find out what the more hair-raising examples of fraud and abuse were.

These are the instances that stood out for his team – only one of which qualifies as definite, unvarnished fraud.

High-end hearing aids – that aren't anything of the sort.

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Medical schemes make rich provision for hearing aids, because they are highly specialised and highly personalised pieces of equipment.

Except when they are not.

"We have audiologists buying cheap stuff from China, importing it in droves," says Midlane. "It's an amplifier, not a hearing aid, and it works for two weeks, but they charge the maximum amount for it."

That is typically around R15,000 – for devices bought for a couple of hundred rand.

The implausibly hard-working and versatile psychologists

Statue Of Sigmund Freud By Oscar Nemon Getty

Psychologists set off the alarms often, Midlane says.

"We have cases where the guys are charging for seeing a patient two hours every day, five days a week, and then you look and find the patient is one year old – and the psychologist is not even a child psychologist."

That is suggestive, but not definitely fraud – because who is to say a patient does not require help for 10 hours a week?

Dieticians roaming hospital wards and asking expensive questions

Photo by Brent Stirton/Getty Images for the GBC

"We find dieticians going up to [medical aid] members who are in hospital and asking 'so how do you find the food?'," says Midlane.

The reputation of hospital food notwithstanding, groggy and ill people tend to be polite and decline to complain. This makes for a short conversation – or consultation, as such dieticians claim.

"They take the membership number and submit a claim," says Midlane.

Some dieticians even submit a claim for consulting the same patient again the next day. It is not clear what help they provide – but it could qualify as a consultation.

R187,000 per hour to treat stab wounds

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In March, says Midlane, a single specialist submitted a claim that came to R212,000 for a 68 minute operation. 

The patient had been stabbed multiple times, and the specialist submitted the maximum claim possible for a stab wound for every single one – to come in at a rate of just over R187,000 per hour.

That seems like an honest, if large, mistake, but it is not.

"He's defending it," says Midlane. "He says he is entitled to charge that."

A dermatological specialist recently did the same thing while treating burns.

The pharmacy-slash-sheep-farm

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Independent pharmacies, where there is no corporate oversight of the books or auditing of stocks, is the source of a great deal of fraud, Midlane says. They also tend to be under pressure as the big chains steal away their customers, and so more likely to dabble in fraud.

Most of the scams are obvious: submitting a claim for more expensive medicine while dispensing a generic and pocketing the difference, or colluding with customers to submit claims for medicine while giving them nappies and baby milk instead.

But some are on a different level altogether.

"There was a farmer in the North West who was giving people a sheep once a month as long as he could claim against their medical aid once a month," says Midlane.

That, at least, is definitely fraud, but Midlane still has sympathy.

"It is economic pressure," he says. "The worse times get, the more desperate people get."

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