Report fraud – it affects everyone

Medical aid fraud is becoming increasingly problematic in South Africa and the rest of the world.

This type of fraud refers to when someone intentionally lies to gain access to medical funds or submitting false or altered claims. This is a crime and a civil law violation which could result in one serving time. 

Medical aid fraud affects everyone who is part of the Scheme and should be reported immediately, if suspected.

Be on the lookout for fraud

Fraud may be committed in many ways.  We have listed a few common methods below.  Please be vigilant and report fraudulent activity as soon as possible.

Merchandising

By law, a medical scheme may only pay for specific healthcare items such as medication and prescription glasses. Claiming for general items like sunglasses, nappies, sport supplements or other non-medical items from a medical scheme is a crime.

Card farming

We only budget for our members’ medical expenses. It is illegal to allow a non-member to use a member’s membership card for medical treatment or medication.

Cosmetic surgery

Most medical schemes don’t pay for cosmetic surgery because they are optional procedures that may not necessarily impact the members’ health. It is unlawful to claim for cosmetic surgery under another procedure code.

ATM scams

A Healthcare Professional and a member may work together to attempt to steal money from the Scheme. The Healthcare Professional sends a claim for a service the member didn’t receive or overcharges for the service they gave and they pay the member cash for taking part in fraud. This is called an “ATM scam” because the member withdraws money from the Scheme. 

Altering Healthcare Professional Invoices or Claims

A Healthcare Professional is obliged to submit a claim that contains prescribed information in order for the Scheme to fund the claim from members’ benefits.  It is illegal to amend or duplicate a claim to include additional treatment not rendered in order to receive additional funding from the Scheme. 

What can you do to fight fraud?

• Check your claims and statements. Ask your Healthcare Professional for a copy of your claim and read the claim to make sure that it only lists services and medication that you have received
• Keep your membership card safe. Do not provide your membership card to anyone who is not a member
• Be careful if a Healthcare Professional says “they can make a plan”. Don’t accept any offers to make the amount you have to pay yourself less on any service or item
• If you’ve just joined the Scheme, tell us about any medical conditions you already have
• Tell us if someone approaches you with an idea to steal money from the Scheme or if you know of someone who is committing medical aid fraud. 

Ways to report fraud

Should you suspect any fraudulent behaviour relating to your healthcare cover, you may anonymously report this by using the following details to contact us:

• Toll-free phone number: 0800 004 500

E-mail: bankmed@tip-offs.com