Fight fraud to keep the cost of healthcare down


Since fraud drives up medical inflation – fraud affects everyone. 

This means medical care and your medical scheme contributions go up more than they would otherwise. Most members and healthcare providers are honest; only a few dishonest people are responsible for the problem.

Fraud is a serious matter! LA Health’s board of trustees has a Zero tolerance policy towards fraud and has recently terminated several memberships due to fraud. We hope you will join us in stamping out this crime! It is your medical scheme money that they are stealing.

Fraud happens when someone intentionally lies or twists the truth for financial gain. Unfortunately, this happens to medical schemes when, for example, a doctor claims for a service they did not deliver or a pharmacist charges for a brand-name medicine but gives you the generic instead and keeps the extra money.

People who commit fraud don’t just steal from LA Health, they steal from you and other members. We put your monthly contributions together and pay claims from the pool. Help us pay as many claims as possible by reporting fraud. You don’t have to give your name, you just have to tell us if you suspect fraud.

Be on the lookout for these kinds of fraud

Merchandising

By law, a medical scheme can only pay for specific healthcare items such as medicine and prescription glasses. Claiming for general wellness items like sunglasses, nappies and sport supplements or other items from a medical scheme is a crime.

Card farming

We only budget for our members’ medical expenses. It is illegal to allow a non-member to use a member’s card for medical treatment or medicine.

Cosmetic surgery

Most medical schemes don’t pay for cosmetic surgery because they are optional procedures that don’t directly affect members’ health. It is unlawful to claim for cosmetic surgery under another procedure code.

ATM scams

A healthcare provider and a member can work together to attempt to steal money from LA Health. The provider sends a claim for a service the member didn’t receive or overcharges for the service they gave, and they pay the member for taking part in fraud. This is called an ATM scam because the member withdraws money from the Scheme.

What can you do to fight fraud?

  • Check your claims and statements. Ask your healthcare provider for a copy of your claim and read the claim to make sure that it only lists services you’ve received.
  • View and update your personal information regularly to make sure you always get payment notifications from us. Log in to www.discovery.co.za, choose Update Your Details and follow the prompts. Otherwise call 0860 103 933.
  • Keep your membership card safe. Don’t give your card to anyone who is not a member.
  • Be careful if a healthcare provider says “they can make a plan”. Don’t accept any offers to make the amount you have to pay yourself less on any service or item.
  • If you’ve just joined the Scheme, tell us about any medical conditions you already have.
  • Tell us if someone approaches you with an idea to steal money from the Scheme or if you know of someone who is committing medical aid fraud.

Use our anonymous fraud hotline to report fraud

We don’t have to know who you are to take your report seriously – you can call our fraud hotline 0800 004 500 anonymously.

References

Money Marketing. Fighting fraud in the healthcare industry, 17 October 2017. Accessed 28 June 2018

Personal Finance. Medical scheme's fight against fraud and abuse is paying off, 25 March 2018. Accessed 28 June 2018

Times Live. Discovery uncovers more than R500m in fraud, 19 January 2018. Accessed 28 June 2018