SCHEME RULES
AGM
INFORMATION ARCHIVE
BOARD OF TRUSTEES CHARTER
DISPUTE RESOLUTION
FRAUD
PAIA
POPIA
How fraud affects our daily life
Healthcare fraud costs the South African healthcare system billions of rands each year. Medical schemes are among the biggest victims. This makes healthcare fraud one of the largest taxpayer rip-offs.
Organised crime rings hatch many schemes. Hospital chains, individual employees, doctors and even patients can be involved – as victims or perpetrators.
The impact of this on you is summarised below.
Exhaustion of benefits
Your benefit limits might be drained by worthless or unnecessary treatment that never occurred.
False medical records
Your medical records may contain false information about illnesses, diseases, injuries or other problems you never had, but claimed for. Your information is available to the Scheme, so you could have been categorised as a high-risk member, e.g. you might have claimed for diseases that your life insurer will in future decline to cover because it was not disclosed on your application form.
Increases in contribution rates
Your monthly contributions may be increased because the Scheme passes the cost of fraud onto members.
Criminal record
Upon successful completion of a criminal case, the member or service provider might end up with a criminal record, which may affect his or her reputation and can lead to the loss of jobs or income.
About Fraud
The definition of fraud is the intentional misrepresentation of fact, which causes prejudice or potential prejudice of someone.
This relates to medical scheme fraud in the following way: The deliberate misrepresentation of fact or claim with the intention of letting the medical scheme pay and lose money, or potentially lose money, to the detriment of all medical scheme members.
By this definition it follows that medical aid fraud is a criminal offence in terms of criminal law. The industry is said to be losing 15% of all claims to fraud.
How to fight back against medical scheme fraud
- Keep detailed records of treatment you receive. Include all dates, locations, who provided the treatment, what services you received, and what medicine, supplies or equipment were provided.
- Carefully review the billing and summary statements you receive after treatment. Are the treatment dates, doctor’s name, facility locations and medical services the same as you remember? Know what medical equipment and supplies your provider ordered as well.
- Never sign any blank form.
- Ask your healthcare service providers what price they charge and what you will have to pay for personally.
- Avoid door-to-door or telephone salespeople who offer you free medical services or equipment.
- Never give strangers your Polmed membership number or your ID number and other information, especially if they offer you cash or free gifts, treatment or equipment.
- Know what your medical benefits are – what is covered and what isn’t.
Whistle-blowing
Whistle-blowing is key in the fight against corruption and mismanagement, especially of members’ funds, and in strengthening transparency and accountability within Polmed and its external healthcare service providers.
If you suspect that you’ve discovered any fraudulent activity relating to Polmed, you can report it safely, easily and anonymously to the toll-free Polmed Fraud Hotline on 0800 112 811 or SMS 33490 or email us at fraud@medscheme.co.za or information@whistleblowing.co.za
Before dialling, please ensure that you have as much information as possible.
Check the following six golden points before contacting us:
- Full details of the suspected service provider or member;
- Dates and names;
- Organisations that are involved, including phone numbers and addresses (if relevant);
- Amount of money you think was lost;
- Documents and other written material; and
- Other information you think is helpful.