A soon to be identified ‘runner’ provided details of Bonitas Medical Fund members to Mashego, who then billed Bonitas fraudulently, for ‘services’ to these members.

Mashego pleaded guilty under Section 105A of the Criminal Procedure Act 77 of 1951 and was sentenced to five years’ imprisonment, wholly suspended for five years, on the 259 counts of fraud with conditions that include:

• Paying Bonitas back R506k as from 1 August 2018. Failure to pay will result in direct imprisonment
• Correctional supervision for 36 months, which includes community service of 16 hours per month
• House arrest for a period of 36 months (except when going to work)
• Restricted to the Pretoria area for 36 months; and
• Refrain from consuming alcohol, drugs, attending night clubs and taverns.

He was also sentenced to five years’ imprisonment, wholly suspended for five years, on the one count for contravening Section 66 of the Medical Schemes Act and declared unfit to possess a firearm for five years because of the guilty verdict.

Kenneth Marion, Chief Operating Officer of Bonitas said, “We identified a sharp spike in his claims and some members contacted the Scheme complaining about claims submitted on their accounts without their knowledge and no service having been rendered to them. We are indebted to the whistle blowers and to SAPS for ensuring that he was convicted and sentenced and for other recent convictions and sentencing we have had in the recent months.”

It is estimated that 15% of claims in the healthcare industry contain an element of Fraud, Waste and Abuse (FWA). For a scheme of Bonitas’ size, this translates to a loss of R190m. “To address this”, says Marion, “We implemented initiatives against FWA, including hospital and pharmacy claim analytics. The result was the identification of FWA of R129.8m, with R31.2m recovered in 2017.” The Scheme further benefitted from R75m in potential savings.

“Five imprisonment sentences have been handed down by the judiciary – clearly indicating a zero tolerance approach to this white collar crime.”

According to Section 66 of the Medical Schemes Act, medical aid fraud, committed either by a member or a healthcare practitioner, is a criminal offence which carries a fine or imprisonment or both. In the instances where a healthcare provider is guilty of committing fraud, all fraudulent claims are reversed and the healthcare provider is reported to the relevant regulatory body and a criminal case opened.

A member found guilty of committing fraud will have their membership terminated. One member was terminated by Bonitas during quarter 2 of 2018 for involvement in fraudulent activities. All fraudulent claims submitted will be reversed and the member will be liable for them. A criminal case will also be opened. In addition, members who commit fraud may also have their employment jeopardised – especially in cases where their medical aid contributions are subsidised by their employer.

“The repercussions of fraud are widespread but it has a very direct impact on each and every member of the Fund,” explains Marion. “Medical schemes are owned by their members and when money is defrauded from the Scheme it can contribute towards increased premiums. In fact the money we recovered last year could have been used to pay for around 57,000 more GP consultations or 18 lung or liver transports.”

Members need to be vigilant

“We believe that our most invaluable tool against FWA remains our members,” says Marion. “To assist them to be proactive in joining us in the fight, we have a toll-free fraud hotline (0800 112 811) to report any incidents of suspected fraud, waste and abuse and encourage them to use it.

“In our experience, the biggest single deterrent is making it known that we are actively investigating every suspicious or unusual claim or activity. Education in terms of the relationships with medical aids, their members and the healthcare providers goes a very long way in curbing the abuse of medical aid benefits and, as such, our approach to fraud management speaks to this education component in all the matters we deal with.”

Who are the culprits?

The culprits are not just medical practitioners. Guilty parties are found all along the healthcare delivery chain – from medical practitioners through to employees, service providers and members. There has also been an increase in collusion between members and healthcare providers.

The trends

Marion says fraud may not necessarily be on the increase but the high level analysis means medical schemes are uncovering substantially more fraud than previously. Current trends seem to be ‘phony doctors or medical practitioners’ who submit claims, using another doctors’ practice number. Sometimes this is done in collaboration with members.

Other fraudulent activity

Waste and abuse is far higher than fraud and is more easily quantifiable in terms of values as it is usually a clear contravention of tariff codes or a rule that exists. Most of the common practices include:

1. Billing for services not rendered (over billing);
2. Using incorrect codes for services (at a higher tariff);
3. Waiving of deductibles and/or co-payments;
4. Billing for a non-covered service as a covered one;
5. Unnecessary or false prescribing of drugs; and
6. Corruption due to kick-backs and bribery

Here are some tips of members of medical aids to help prevent fraud

• Keep your personal medical scheme details (such as your membership number) private
• Check your medical scheme statements to make sure that all claims are correct and that you actually received the services you are being charged for
• Keep your membership card safe
• Report any suspicious activity call 0800 112 811

“We are encouraged at the increased reports by our members. Fraud directly impacts them so we all need to be more diligent in checking our billings and questioning unnecessary procedures. The contribution by members, combined with our internal fraud-tracking system and investigations by SAPS and prosecution by NPA will all work together to put a stop to fraud, wastage and abuse and help reduce spiralling healthcare costs. It’s a win-win for everyone,” concluded Marion.

Toll-free fraud hotline (0800 112 811)