‘15% of all medical scheme claims are suspect’


Medical Cover /  / 

Reining in fraud, waste and abuse topped the agenda at the release of the annual report of the Council for Medical Schemes (CMS).
Photo: File

Reining in fraud, waste and abuse topped the agenda at the release of the annual report of the Council for Medical Schemes (CMS), which was presented to Parliament on Thursday last week.

It has identified an increase in claims, scheme utilisation and high-cost cases, compounded by modest growth since 2012, and overly generous remuneration for principal officers and trustees.

CMS chief executive Dr Sipho Kabane says fraud, waste and abuse constitute 15 percent of all medical scheme claims.

Some of the issues the council identified relate to “collusion in the appointment of service providers, the irregular placement of schemes under curatorship, irregular spending on service providers, lifestyles not matching salaries, and close and corrupt relationships with entities that the council regulates”.

The Competition Commission’s Health Market Inquiry found similar abuses. Its report, released earlier this month, found the system was being milked due to a lack of controls by the Department of Health, and plagued by the high costs of cover and a significant over-utilisation of services without a demonstrative benefit to health outcomes.

It recommended reforms to stabilise the sector, including that trustee and principal officer remuneration be capped, linked to scheme…



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