According to the Council of Medical Schemes, up to 15% of all medical aid clams are associated with fraud. Going back to 2017 figures, the expenditure was about R122 billion. This means that the council is looking at R122 Billion of fraud, waste and abuse.
In terms of the service providers, we have been made aware of medical aid schemes submitting false claims and over billing and falsification of patient information.— Dr Sipho Kabane, Acting chief executive and registrar - Council of Medical Schemes
Acting chief executive and registrar of the Council of Medical Schemes, Dr Sipho Kabane, said as the council's aim is to regulate the entities that are under its umbrella. These include: medical aid schemes, administrators, and brokers.
He says the Health Professions Council of South Africa, whose role is to regulate service providers, has been operating in a different manner, and that is why fraud, waste and abuse has thrived over the years.
We are sitting with a pile of complaints from members and service providers on issues around fraud and we wish to resolve these issues as soon as possible.— Dr Sipho Kabane, Acting chief executive and registrar - Council of Medical Schemes
Kabane said that, in some cases, clients also help the service providers to commit fraud.
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