How does medical scheme fraud affect me and other service providers?
Unfortunately, fraud relating to
medical schemes claims affects medical scheme members by leading to:
- Increases in your membership fees
- Reductions in your benefits
- Loss of trust
Medical scheme members and
medical practitioners can commit medical scheme fraud. Fraudulent activities on
the part of members include:
- Allowing unregistered family members or
friends to visit the doctor while they pretend to be a registered
beneficiary.
- Colluding with medical practitioners by
accepting a bribe in return for allowing the medical practitioner to
submit false claims to the medical scheme.
Fraudulent activities on the
part of medical practitioners include:
- Submitting claims for the treatment of a
beneficiary (or beneficiaries), whilst never actually having provided
medical services to the patient(s).
- Submitting claims for services never
rendered after bribing members to allow the medical practitioner to misuse
a patient’s medical scheme membership.
- Altering treatment dates on accounts
where claims are rejected because these were received outside the
submission period in order to qualify for benefits.
- Over-servicing, that is the dispensing of
unnecessary medication, medical devices or conducting unnecessary tests.
- Claiming for procedures which are allowed
in terms of Scheme Rules, but then performing an alternative procedure
which isn’t covered. For example, claiming for prescription lenses and
then dispensing sunglasses.
Report Fraud
Iso Leso is committed to
eradicate fraud through implementing the following measures:
- The Iso Leso forensic investigations
department is dedicated to the investigation of all allegations of fraud.
- Iso Leso has contracted the services of
an independent forensic company to assist with investigations into
fraudulent activities.
- Iso Leso conducts an overall actuarial
audit of product and service provision against claims received ensures the
delivery of a transparent and efficient process.
- Routine enquiries and checks with medical
scheme members to ensure quality service delivery.
- Iso Leso is a member of the BHF Fraud
Management Unit (HFMU) and our fraud management interventions abide by its
code of practice.
Here’s what you can do to help.
Report fraud by:
- Phoning our call centre on 011 340
9200 – you can choose to remain anonymous.
- Emailing fraud@isoleso.co.za
