Do not involve yourself in a fraudulent act
People who commit medical aid fraud might think that they're scoring off a faceless entity, but medical schemes are non-profit entities. Fraudsters' actions affect medical scheme members directly. Medical aid fraud is one of the factors that contributes to how much contributions increase each year and forces medical schemes to introduce more rules to prevent abuse.
You can help limit the impact of medical aid fraud by reporting it to us if you even slightly suspect someone of committing fraud.
What to look out for
- False claims: Claiming for services that did not take place.
- Merchandising: Submitting a claim for non-healthcare items, for example, sunglasses.
- ATM scams: Receiving cash and submitting a claim for healthcare services.
- Card farming: Allowing a non-member to use the membership for treatment.
- Cosmetic surgery: Claiming for cosmetic surgery under a covered procedures code. Medical schemes generally do not cover cosmetic surgery.
- Non-disclosure: Not telling the medical scheme about medical conditions they already have and joining the scheme specifically to claim for those conditions.
- Dispensing fraud: Giving a patient the generic version of the medicine, but claiming medicine is dispensed and the claim is received for the original drug at a higher cost.
Consequences of committing a fraudulent act by members of the Scheme
According to the rules of the Scheme, your membership could be terminated if you commit fraud. The reason for your termination will be shared with your employer as the employer will need to be notified not to deduct your medical scheme contribution from your salary.
Report fraud
Toll-free phone: 0800 004 500
SMS: 43477
Toll-free fax: 0800 007 788
Email: discovery@tip-offs.com
Post: Freepost DN298, Umhlanga Rocks 4320
You can remain anonymous when you report suspected medical aid fraud.