Fraud Waste and Abuse

Fight Fraud | How does Fraud affect me and other service providers | Report Fraud

Fight Fraud

Fraud is an intentional and unlawful misrepresentation which actually or potentially harms another party. In other words, someone intentionally lies to gain an illegal advantage and their victim suffers a loss because of that lie.

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