Discovery, like other medical schemes, spends a fair amount of time battling fraudulent claims.

Last year alone, they discovered R555 million in fraud and wasteful medical expenses.

The company employs 100 analysts and investigators, alongside a proprietary forensic software system that uses algorithms to identify any unusual claim patterns.

They also have a super swanky building in Jozi, and can’t get their policies together when it comes to gender politics, but that’s beside the point.

Here’s BusinessInsider with more on the healthcare scams:

“Invaluable tip-offs from whistle blowers also help to identify fraud, waste and abuse,” says Discovery Health CEO, Dr Jonathan Broomberg.

More than 5,400 suspicious cases were reported last year, with 75% confirmed to be irregular.

“Although we have secured large recoveries as a result of our fraud, waste and abuse avoidance efforts, we believe that this is only part of the story, and fraudulent activity and billing abuse most likely costs medical aid schemes several billion rand per year,” Broomberg said.

The most common type of medical scheme fraud, a whopping 40%, was for claims submitted for services not rendered. Another problem was the incorrect procedure codes supplied by medical practitioners.

Limpopo continues to be the biggest problem region: 201 cases of fraud and waste per 100,000 Discovery medical scheme members have been confirmed.

Limpopo is followed by the Free State and the North West (89 cases each).

The Western Cape and Northern Cape had the lowest prevalence of fraud and abuse cases among members.

Some of the biggest scams of 2018 included a nurse who worked with a nursing sister to submit fraudulent claims under the sister’s practice number. A criminal case has been registered against them for fraud of more than R3 million.

There was also a big scam in oxygen rentals. One supplier of oxygen concentrators and portable concentrators charged Discovery more than R2 million, but it was then revealed that invoices were fiddled with and that members weren’t getting the units. Some of the oxygen devices were sourced from China and prices inflated ten times.

The worst thing about healthcare fraud is that negatively effects medical aid members by driving up premiums and depriving them of benefits.

It’s also stupid, because one way or another, you will more than likely get caught.

[source:businessinsider]