Know how you can combat healthcare fraud


Combating healthcare fraud is a joint effort

Healthcare fraud is an ongoing challenge. Fraud undermines LA Health’s reputation, it impedes our fight against rising healthcare costs and it comes down to stealing from our members.

Identifying and reporting anyone engaging in fraudulent activity against the Scheme is the only way we can safeguard the interests of our honest members, healthcare providers, employees and brokers.

Systems that detect healthcare fraud and identify culprits

The Scheme’s Board of Trustees has zero tolerance for fraud in any form.

Medical schemes have to protect themselves and their members. Irregular or over-claiming costs the industry millions every year and is on the increase. As the administrator of LA Health Medical Scheme, Discovery Health has a Forensic Department with full-time forensic investigators who investigate and report any fraudulent activity in the Scheme.

Combining actuarial, statistical, forensic, clinical and operational systems processes designed to minimise the possibility of fraud and raise red flags when something doesn’t seem right, they make it just about impossible for suspicious activity to go undetected.

What is considered healthcare fraud?

Healthcare fraud occurs when money reserved to provide healthcare services is wrongfully obtained from a medical scheme. Fraud that affects LA Health Medical Scheme can take place in many different ways, including:

  • Using forged or false documents, such as false medical reports or applications
  • Non-disclosure of pre-existing conditions to avoid having them excluded
  • Giving false banking details so we are unable to deduct contributions, even after benefits have been used extensively
  • Claims fraud, where a member and provider work together, for example to buy sunglasses but claim for them as prescription glasses
  • Services not provided, which means a provider claims for a procedure, for example an ultrasound, without performing it
  • Doctors admitting patients to hospital unnecessarily
  • Members belonging to two medical schemes at the same time and claiming from both

Throwing the book at fraudsters

Healthcare provider claims are paid in good faith. Claiming patterns and behaviour are only properly reviewed and validated after payment has been made. Discovery Health has a large database, which allows for detection of unusual conduct or discrepancies. If an irregularity warrants an investigation by the Forensic Department, the relevant provider or member is always given the opportunity to respond.

If, however, it becomes clear from the investigation that someone has committed fraud, the perpetrator may face criminal or civil charges. If a healthcare professional is involved, fraudulent activity may result in the provider losing a career in healthcare by having their required professional registration cancelled.

Members guilty of fraud could lose their healthcare cover altogether and employees could face disciplinary action and be fired. Financial advisers found to be involved in fraud will have their licences revoked and be reported to the Financial Services Board and the Registrar for Medical Schemes.

Significant fraud recoveries

Over the last three years, the work done by the Discovery Health Forensics Department helped the Scheme to recover more than R12.5 million. This is obviously a good thing as it means members did not have to pay for these unnecessary expenses through contributions.

How you can help combat fraud

Never turn a blind eye. If you have even the slightest suspicion that someone is committing fraud, report all information you have to the Discovery fraud hotline, using any of the following contact details:

You may remain anonymous and we will handle all calls and contact in strict confidentiality. We will list any person found guilty of committing fraud on a register and take steps to recover any money members or the Scheme may have lost in the process.