Report: South African medical scheme claims riddled with fraud


South African private medical schemes spent R160.6 billion on health care benefits in 2017, with policyholders paying an extra R31.8 billion in out-of-pocket expenses for private healthcare services.

The expenditures incurred by schemes on healthcare benefits make up an increase of 6.04% from R151.2 billion in 2016. The bulk was incurred for medicines, followed by allied health, and specialists, the annual report of the Council of Medical Schemes (CMS) shows.
Acting CMS CEO Sipho Kabane highlights the ongoing scourge of fraud, waste and abuse by the unethical behaviour of some providers. This is sometimes in collusion with members of medical schemes.

About 15% of all the claims submitted in 2017 were due to fraud, waste and abuse, he says. “Unfortunately this has been a major contributor to annual member contribution increases,” Kabane says. “The CMS will continue to monitor expenditure on PMBs to improve quality and reliability of expenditure data, with the purpose of protecting the right of beneficiaries’ access to these benefits.”

“In some instances providers often informed providers that they suffered illnesses which qualified for PMB payments, when this was not the case,” says Kabane.

The report also notes that the number of registered medical schemes decreased to 80 schemes in 2017, from 82 in 2016. This is mainly a result of the liquidation of the Community Health Medical Schemes and a voluntary amalgamation between Metropolitan Medical Scheme and Momentum Health.