Fin24 reports that according to the Government Employees Medical Scheme (GEMS), which is SA's biggest medical scheme for public servants, the country is losing R22 billion a year to fraud, waste and abuse in the healthcare industry.
In the past year, scams uncovered by GEMS included pharmacies colluding with members and other healthcare providers to create "cash-backs". Some specialists billed for services not rendered. With dieticians, the biggest problem was "wellness days". Whereas such days were for screening, some dieticians claimed full consultations and other services not rendered. "We are losing lots of money due to these types of offences," said GEMS senior manager for operations and risk Ishmael Mogapi during a symposium held on Friday. Mogapi said GEMS was also losing millions of rands to wasteful behaviour and abuse of the healthcare system. Mogapi's presentation showed that GEMS investigated roughly between 40 and 60 cases each month between January and August. Most of those related to pharmacies, followed by GPs, dieticians, physiotherapists and registered nurses. KwaZulu-Natal had the highest number of cases, followed by Gauteng and Limpopo. Mogapi said many of the investigations were sparked by tip-offs that the scheme received through its hotline. But it also picked up a lot of red flags through analytics done internally. GEMS chairperson Dr Sebayitseng Hlatshwayo said while there were no studies done to determine the exact extent of fraud, waste and abuse in the healthcare industry in SA, various schemes estimated that these offences translated to between 5% and 15% of all medical claims.
- Read the full original of the report in the above regard by Londiwe Buthelezi at Fin24 (subscriber access only)
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