Call us directly: 0861 111 501

Licence: CMS BR5404 & FSP 19742

Authorised Financial Service Provider

CMAC Licence: FSP 17112  CMS: ORG 35

James Easton - Licence: CMS BR 39065

Dear Financial Advisor

Fraud waste and abuse continues to threaten the sustainability of the healthcare industry. Over the past few years, we’ve have seen a rise in fraud waste and abuse as South Africa’s economic growth continues to slow-down. This puts pressure on businesses and consumers to find ways to sustain their livelihoods. Unfortunately, this sometimes means businesses and consumers may choose to sustain their livelihoods illegally. Bonitas is at the forefront of fighting fraud, waste and abuse. These are some of the interventions we’ve made and trends we’ve noticed concerning this issue.
Over R16 million recovered from fraudulent pharmacy claims
Between 2016 and 2017, we recovered over R16 million in fraudulent claims committed by 90 independent pharmacies. This has prompted us to focus on growing our Designated Service Provider network of retail and corporate pharmacies.
Other alarming trends include poor record-keeping practices, with often very little evidence of supplier invoices or original prescriptions available. We have been auditing pharmacy claims routinely to ensure that the medication claimed for by pharmacies has been purchased by members. Using the claims scoring analytical capability, we are able to identify irregular patterns of behaviour by any pharmacy that requires further investigation.
Some healthcare facilities continue to encourage wasteful expenditure
Despite a lack of membership growth in the medical scheme industry, many healthcare facilities still manage to increase occupancy and expand their footprints. These profit-driven organisations continue to encourage wasteful expenditure in the system. For example, a day in hospital for pneumonia is more expensive than taking antibiotics at home and therefore staff at facilities may encourage members to go to hospital.
We now have a dedicated forensic unit which solely audits facility claims and ensures that invalid or irregular claims that were overpaid are recovered. We have also seen that some of these healthcare facilities are operating with expired licenses and some are even offering services that they are not accredited for, which is unlawful.
Misrepresentation as mental health facilities
In addition, we have noticed some wellness spas and retreats masquerading as mental healthcare facilities with no registered psychiatrists or psychologists on the premises. This comes at a substantial cost to Bonitas with no clinical benefit to the member. Certain physiotherapists and dieticians operating in the hospitals are also acting as if they are there on instruction from the doctor and then submit a claim to us, when in fact the treating doctor is not aware that they were servicing the patient. Once again this costs the Fund a substantial amount of money and has no clinical benefit.
Our primary focus is to eliminate these fraudulent, wasteful and abusive practices which escalates healthcare costs impacting negatively on your clients. We will continue to keep you updated in this regard.
Kind regards
Bonitas Medical Fund