Category Fraud/Crime

Second Medical aid fraud conviction in two months

02 October 2018

In the last two months, Bonitas Medical Fund has succeeded in having two healthcare practitioners convicted and sentenced for fraud against the Scheme and its members.

In August: On Wednesday, 01 August, Mr Wandile Theophilus Mashego, an audiologist and speech therapist practising in Pretoria, was found guilty of 259 counts of medical aid fraud and 1 count for contravening Section 66 of the Medical Schemes Act. Mr Mashego was ordered to pay back R506k as well as being subject to stringent conditions including house arrest, a suspended prison sentence, community service and correctional supervision.

Last week: On 26 September, Mr Henny Tinyiko Mavasa (31), was found guilty of 60 counts of medical aid fraud and 60 counts for contravening Section 66 of The Medical Schemes Act. The case was brought against him by Bonitas and he was sentenced in the Johannesburg Specialised Commercial Court. He had been submitting fraudulent claims on members over a period of two years.
Mavasa pleaded guilty under Section 105A of the Criminal Procedure Act 77 of 1951 and was sentenced to a fine of R60k or 3 years imprisonment. He was also sentenced to a further 3 years imprisonment, suspended for 5 years. It was noted by the Court that the guilty party had already paid R87k back to Bonitas, which was the amount the criminal case had proven beyond reasonable doubt.

Focus on Fraud
Kenneth Marion, Chief Operating Officer of Bonitas said, ‘Over the past few years we have renewed our focus around Fraud, Waste and Abuse (FWA) and implemented initiatives to stop criminal activity and recoup costs which we can invest back into the Fund. We have had a number of successes with R31.2 million recovered in 2017. We have also seen seven imprisonment sentences handed down by the judiciary. This sends a strong non-tolerance message to fraudsters in the medical industry.
‘Around 15% of claims in the healthcare industry contain some element of FWA,’ he explains. ‘This form of corruption is unacceptable. Last year it is estimated that R10 billion was lost through healthcare fraud and for a Scheme the size of Bonitas, this translates to around R190 million. Money that could be put to better use by channelling it towards increasing benefits for members.’

The impact of FWA
‘The repercussions of fraud are widespread but it has a direct impact on every member of the Fund,’ says Marion. ‘Medical schemes are not for profit and are in fact owned by their members. So when the Scheme is defrauded, it impacts funds to pay for claims and can contribute towards increased premiums. Last year R31.2 million was recovered.

What is Medical Aid Fraud?
According to Section 66 of the Medical Schemes Act, medical aid fraud, committed either by a member or a healthcare practitioner, is a criminal offence which carries a fine, imprisonment or both.

Being vigilant
‘Our most invaluable tool against FWA remains our members,’ says Marion. ‘To assist them to be proactive in joining us in the fight, we have a toll-free fraud hotline (0800 112 811) to report any incidents of suspected fraud, waste and abuse and encourage them to use it.
‘In our experience, the biggest single deterrent is making it known that we are actively investigating every suspicious or unusual claim or activity and to also report convictions. Education goes a very long way in curbing the abuse of medical aid benefits in terms of the relationships between medical aids, healthcare providers and members.’

The guilty parties
Culprits are found all along the healthcare delivery chain – from medical practitioners through to employees, service providers and members. There has also been an increase in collusion between members and healthcare providers.

Tips to help prevent fraud
· Keep your personal medical scheme details (such as your membership number) private
· Check your medical scheme statements to make sure that all claims are correct and that you actually received the services you  are being charged for
· Keep your membership card safe
· Report any suspicious activity call 0800 112 811

‘We are indebted to the whistle blowers and to SAPS for helping us get perpetrators like Mr Mavasa into our courts and then convicted and sentenced,’ concluded Marion.

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