Category Healthcare
SUB CATEGORIES General  |  HIV |  Medical Schemes | 

SA medical schemes conned by 'healthy patients'

21 May 2007 Telemed

Local medical schemes are falling victim to an increasing trend of members abusing benefits provided, by making unnecessary claims, for a variety of reasons. Many are 'professional patients', a term used to describe otherwise healthy medical aid members who pretend that they are or in some cases believe that they are genuinely sick. This has a knock-on effect by absorbing resources and funds that could have been better used by those that most need it.

Whilst 'professional patients' are often recognized as having a genuine psychiatric condition, it is often left undiagnosed or even ignored by service providers. A member with this psychiatric condition can very quickly drain resources and some unscrupulous service providers may even exploit this condition for their own financial gain. It is for this reason that more attention must be paid to the claims history of members in order to spot those who might more appropriately avail themselves of psychiatric assessment. Whilst often an expensive route to take in the short term, it could potentially be a money saver for the medical scheme and therefore benefit the majority of its members.
It is the members of medical aid schemes that end up compensating these questionably unstable malingerers by paying ever increasing premiums. Though by no means the sole reason for premium increases, it would appear to be an ever-more evident factor.

For far too long, medical schemes have been forced to swallow this bitter pill and have had very little opportunity to deal with or redress this concern. That is until now.

Local medical aid scheme, Telemed have put in place an action plan to deal with this phenomenon. This includes closer monitoring of members' GP visits, monitoring of tests and procedures, and monitoring of prescription medication, all notified as key areas in which `professional patients' make false claims.

Carel Stadler, CEO of Telemed, explains, "At Telemed we are not prepared to compromise our service, by pandering to the whims and fantasies of the minority who use doctors, hospitals and medication as a form of escapism. By putting in this methodology, we will be able to focus more funds on those who really need care in South Africa."

Stadler continues, "Related to this trend is the ease with which some service providers put their patients on chronic medication, this is also an area of major concern. Very often, the patient, 'professional' or otherwise, is left on chronic medication for years without appropriate monitoring, once again draining valuable resources."

Stadler adds "This is far reaching for South Africans and for the industry as a whole. It's important for all medical aid members to look at how their scheme monitors how freely they spend their money. It is as important for local medical aid schemes to stop this shocking trend by putting in similar measures. It could cost dearly to those who need the support most."

Telemed is this year celebrating its 85th birthday, making it one of South Africa's most established medical aid schemes. Its growth has been built upon a service-driven mentality and an intensely local focus on its members, evident in its new campaign to curb and monitor claims behaviour more thoroughly.

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