Medical aid fraud and waste and abuse are rife in SA, according to Jan Mothibi, head of the Special Investigating Unit, reports Weekend Argus. “Fifteen percent of all medical aid claims are associated with fraud, waste and abuse.
Nir Kaminer, speaking at a Board of Healthcare Funders conference, from Ireland’s Medical Reviews International, said that part of the wastage comes from “supplier-induced demand”. “Patients are under the impression that more is better – more diagnoses, medications and surgeries,” he said.
“According to the 2018 Competition Commission report, R24billion of the R160bn in claims paid annually was on unnecessary care.” This included thousands of unnecessary caesarian sections.
The wastage was also widespread in orthopaedic care, where patients received joint replacements that were not medically required, he said. There were also unexplained increases in the charges of specialists like dermatologists.
Dr Gunvant Goolab, principal officer of the Government Employees Medical Scheme, called for hospitals to be more transparent with regard to pricing.
The bulk of private health-care claims paid went towards costs incurred in hospital, rather than for medicine purchased at a pharmacy, or doctor visits.
“Nearly R2 out of every R3 spent on private health care goes to in-hospital costs. Hospital pricing transparency will make health care more affordable.”Weekend Argus report