Help us to protect your Scheme against Fraud

The Industry says up to 15% is lost to fraud. Help us to protect your Scheme against Fraud.

  • What can happen if fraud is proven?
  • In the case of healthcare providers, the following sanctions may be imposed:
  • Reversal of all irregular transactions (e.g. claims);
  • Placing a provider on indirect payment;
  • Reporting a provider to the relevant regulatory body;
  • Recovery of losses through civil or criminal process;
  • Proceeding with a criminal case; and
  • Removal of the provider from any Scheme network for a period of 12 months.
  • In the case of members, the following sanctions may be imposed:
  • Termination of membership;
  • Proceeding with a criminal case;
  • Recovery of losses from the member; and
  • Reporting the member to their employer.
  • What can you do to protect your medical aid scheme against fraud?
  • Scrutinising every SMS notification and statement received from your medical aid.
  • Inform the Scheme of any transactions or procedure that you do not recognise.
  • Tell us if your colleagues often boast about a bargain they came across (such as some miracle weight loss injection from a doctor) and that they did not pay a cent for it because the medical aid paid for it. If it sounds too good to be true it probably is. Report it to the scheme. We will investigate.
  • Immediately report a lost medical aid card to the Scheme. A lost medical aid card can be equivalent to cash in the hands of the wrong people.