Fraud‚ waste and abuse were just three types of corruption that occurred in the public and private healthcare sectors – and fraud in the private healthcare sector alone was estimated at R22bn each year. The Times reports that this is according to Special Investigating Unit head Andy Mothibi, as his unit convened a meeting in Pretoria to establish a forum that would focus on fighting corruption‚ fraud and waste in the healthcare sector.
The forum is part of the expanded Anti-Corruption Task Team (ACTT)‚ a multi-department team formed in 2009 to detect‚ investigate and prosecute alleged cases of corruption. The report says the ACTT’s mandate was expanded in 2014 to include other programmes‚ which included crime operations and intelligence and policy support.
Mothibi said the forum decided to concentrate on the health sector among the most vulnerable sectors. Mothibi said estimates by the Board of Healthcare Funders of Southern Africa were that at least 7% of all medical aid claims in South Africa were fraudulent – and that the figure could be as high as 15%.
He said other studies showed that R24bn of provincial health department expenditure between 2009 and 2013 was irregular. Mothibi added that some of the problems facing the sector included fictitious claims‚ medical aid fraud‚ incidents of bogus doctors and price fixing by pharmaceutical companies.
Mothibi said the unit will work with a number of departments including the Financial Intelligence Centre‚ National Treasury‚ State Security Agency‚ and the Cooperative Governance and Traditional Affairs. The unit would conduct investigations if there was a need‚ conduct civil litigation and also conduct proactive interventions.
“The aim of today’s session is to engage with the stakeholders about one of the sectors that we have identified…to ensure that we achieve an understanding on how parties will collaborate in identifying corruption so that we can channel them to investigating agencies‚” Mothibi said in the report.
He said the forum would like to ensure that it improved the identification of fraud and corruption in the sector. “If they are identified… we ensure that we assess them‚ and where there is a need for further investigation we do that and we have to ensure there are consequences‚ either in the form of civil recoveries‚ disciplinary action or criminal prosecution.”
It is estimated that a staggering five to 15% of private healthcare claims per year are fraudulent, says an eNCA report. The Board of Healthcare Funders of SA’s Katlego Mothodi said: “If you look at the 2017 financial year, there were about R160bn worth of claims in the medical aid sector. Now those percentages relate to anything from R8bn to R22bn that goes out as a result of fraud.”
Mothibi is quoted in the report as saying: “Where we determine that there’s a need for prosecution, where there’s a prima facie case, we take the information and refer it to the National Prosecuting Authority (NPA). It will probably be the case with the Hawks, as well.”
Factors contributing to corruption in the healthcare sector include collusion, ineffective management, conflicts of interest, weak detection strategies and falsified information.
Department of Health chief director Maile Ngake said: “We’re investigating possibilities of corruption and collusion in the department. Our goal is to ensure we reach the depth through interaction with an institution like the SIU to realise that objective.”
The report says one of the challenges is that many in judicial and investigating departments have a limited understanding of healthcare-related matters.
[link url="https://www.timeslive.co.za/news/south-africa/2018-06-06-elite-investigators-to-target-healthcare-fraud-and-corruption/"]The Times report[/link]
[link url="https://www.enca.com/south-africa/siu-turns-attention-to-doctored-health-claims"]eNCA report[/link]