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Medical Schemes
Friday, June 1, 2007
Controlling fraud

Medical schemes are being hit hard by excessive claims from members on high benefit options.

This is according to Medicover’s Principal Officer, Stephan Grobler, who stresses that the claims are not necessarily fraudulent, but rather consistent with a trend to get as much out of the scheme as possible – often without reason. “It is extremely difficult to close loopholes that allow irresponsible use of medical aid benefits,” he comments. “So schemes have no choice but to increase their premiums to remain solvent.”
Despite this Medicover says it has kept its annual increase to below 10% per annum for the past five years, while maintaining and in some cases improving the level of benefits.
“While the industry trend has been to keep increases low, many schemes have slashed benefits at the same time,” he adds explains.
“Our claims ratio has increased substantially in the past two years,” Mr Grobler notes. “In response, we have taken several steps to reduce risk and keep our scheme sustainable. These include filters to reduce fraudulent claims from service providers and from members, as well as additional proof needed in certain categories of claims where there was previously room for manipulation.”
Medicover is a self-administered scheme, which means lower overheads and better control than outsourced administration, and therefore lower cost to the member. It also means efficient service carried out by people loyal to Medicover and transparency in the use of funds.
Medicover also makes use of specialist service providers to manage dental and optometry benefits. This brings significant savings to the scheme and to members through checks and balances put in place by specialist doctors in these fields. Dental Information Systems (Denis) manages dentistry benefits for Medicover and Opticlear has just been appointed to audit optometry claims among other benefits.

Copyright © Insurance Times and Investments® Vol:20.5 1st June, 2007
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