The following frequent fraudulent claims occur in the Healthcare environment:
- Doctors submit claims for services that have not been rendered to patients
- Dispensing doctors and pharmacies provide members with low cost generic medicines and claim for higher cost brand name medicines
- Doctors provide fraudulent sick notes to members and then claim for a consultation from the scheme
- Pharmacies sell cosmetics and other “front shop” items to scheme members, and submit fraudulent claims for “medicines supplied” to the scheme
- Members, in collusion with doctors and hospitals, submit claims for false hospital admissions, in order to benefit from the claims payment
- Members forge and submit claims for services supposedly rendered by healthcare professionals, but which were never actually rendered
- Ghost medical aid submissions (Identity theft)
The financial consequences of this abuse include:
- Possible premium increases
- More thorough validation processes for hospital authorisation requests
- More stringent criteria for accepting members to a scheme
- And for perpetrators, criminal prosecution
Fees – to be agreed with the Insurer or supplier