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Medical Schemes
Thursday, November 26, 2015 - 14:31
Top priority fight

According to estimates by the Healthcare Forensic Management Unit (HFMU) of the Board of Healthcare Funders of Southern Africa (BHF), at least 7% of all medical aid claims in South Africa are fraudulent and the figure could be as high as 15%. 

That adds between R192 and R410 per month to every principal member’s medical aid contributions.

“Fighting fraud is one of Bonitas’ top priorities and, in collaboration with our auditors we have put a series of measures in place to ensure that the scheme is fraud resilient,” says Dr Bobby Ramasia, Bonitas’ principal executive officer. 

“Bonitas already employs an arsenal of sophisticated strategies to deal with the challenge and we have made good progress in enhancing our prevention and detection capabilities. However, as fraud becomes more prevalent and sophisticated, so must the methods we use to combat it,” he says.

Bonitas Medical Fund has entered into a partnership with Helios IT Solutions and international analytics software company FICO which will place the scheme at the forefront of the industry’s fight against fraud, wastage and abuse.

“The solution represents a quantum leap forward in detecting healthcare fraud and mitigating losses and potential savings of 8,7% of claims paid is achievable,” says Ramasia. 

In terms of monetary value, healthcare fraud is one of the leading crimes in the country. It is also the most complex form of financial fraud to detect, monitor and prevent.

Bonitas has been successful in restricting losses to about 3% of turnover. However, even at that relatively low percentage, fraud is costing the scheme more than R260 million annually,” says Ramasia. 

Fraud occurs at all levels along the healthcare delivery chain and involves  employees, administrators, medical scheme members, providers of service as well as healthcare services providers.  However the prevalence of fraud involving collusion between medical aid members and healthcare providers is increasing.  

The FICO solution identifies actual and potential fraud and abuse by monitoring irregular claiming patterns that can lead to early detection and action.

“Once fraud is detected, the case is investigated by our forensic specialists and the appropriate action is taken,” he says.

However, at the same time it is of the utmost importance that investigations maintain a high standard of ethics while adhering to the legal protocols and processes agreed to by the industry.

Fraud wastage and abuse of medical aid benefits is a serious challenge that seriously hampers efforts to solve one of the biggest challenges facing our country - providing affordable, quality healthcare to all South Africans.

Ramasia says an integrated approach to fraud is essential. For this reason Bonitas works closely with the Healthcare Forensic Management Unit at BHF as well as the relevant statutory, regulatory and professional bodies.

“Bonitas supports the view that a collective approach to altering behaviour of those who act fraudulently or inappropriately will have the greatest impact. 

“If perpetrators know that it is more likely that there will be consequences to their actions, they are less likely to commit fraud, wastage and abuse,” he concludes.

Copyright © Insurance Times and Investments® Vol:28.11 1st November, 2015
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