The Government Employees Medical Scheme (GEMS), the second biggest scheme in the country, had a problem in KwaZulu-Natal. Moneyweb reports that it identified this province as the most problematic when it came to fraudulent claims.
In one example, GEMS uncovered irregular claims of R93m by a service provider who had 36 practices registered under its name. But, the report says, they are not alone. Medical aid claims attributed to fraud, waste and abuse cost the sector between R22bn and R28bn a year.
These numbers were revealed at the inaugural Fraud Waste and Abuse Summit organised by industry regulator the Council for Medical Schemes (CMS) earlier this year. They accounted for an average of around 25% of the total healthcare claims paid by the industry in 2017.
It’s clear that the issue is immense, and while various stakeholders in the sector have their own methods and applications to tackle this trend, medical expert Dr Ntuthuko Bhengu says in the report that technological solutions like blockchain, have the potential to drastically curb fraud and wasteful expenditure, if only they could be adopted by the industry.
Blockchain is a type of distributed ledger technology used to record and store transaction records. It is a shared and fixed record of peer-to-peer transactions built from linked transaction blocks and stored in a digital ledger.
The report says given that blockchain is a decentralised system where transactions are recorded and shared among all network participants, by using blockchain, the CMS, for instance, would have access to the immutable audit trail of all interactions between medical schemes, their members and practitioners. This would make it easier for it to detect patterns of fraud. Another benefit to an inter-operable blockchain is that it is secure.Moneyweb report