Bogus medical aid and hospital cash-back claims worth millions of rands have been uncovered by the Government Employees Medical Scheme (Gems), the firm announced this week.
This, it said, followed a comprehensive review of claims submitted by various service providers and included a number of in-hospital claims.
The principal officer of Gems, Dr Guni Goolab, said acknowledgements of debts (AOD) were signed by a number of healthcare service providers, including psychologists, dieticians, psychotherapists and surgeons, who must now pay back more than R5 million in irregular or fraudulent claims.
“Further investigations have led us to a number of claims relating to hospital admissions where either the length of hospital admission was unnecessarily extended or were found to be generally without clinically appropriate reasons,” said Goolab.
Goolab said the scheme also found that KwaZulu-Natal was the worst province for fraudulent, abusive or wasteful claims involving hospital cash-back plans. “Our analysis identified the top-claiming members and providers suspected of the abuse of hospital cash-back plans. One of the scheme’s forensic investigation service providers were subsequently deployed to KZN to launch a full-scale investigation.”
He said their investigations were ongoing and evidence was being gathered with the intention to prosecute the individuals concerned and to recover amounts owed to Gems.
“To date, indications are that there is substance to the allegations levelled at the identified healthcare facilities and service providers. Affidavits obtained, including data analysis, indicate there is sufficient evidence that would warrant the pursuing of criminal charges against certain individuals and institutions,” stated Dr Goolab.
The scheme had undertaken a number of claims risk management activities, including the sanctioning, in terms of scheme policies, of more than 100 healthcare service providers in 2016. Additional actions include the reporting of cases to regulatory bodies such as the Health Professions Council of South Africa.