Report fraud – it affects you directly
Medical aid fraud is becoming increasingly problematic in South Africa and the rest of the world. This type of fraud refers to when someone intentionally lies to gain access to medical funds, or submits false or altered claims.
Submitting fraudulent claims to your medical scheme or allowing someone else to do so not only robs you and other members of future benefits, but also causes contributions to increase.
Fraud happens in many ways
It is not always obvious that someone is stealing from a medical scheme. Here are some ways people try to cheat the system.
By law, a medical aid may only pay for specific healthcare items such as medicine and prescription glasses. Claiming for general items like sunglasses, nappies, sport supplements or other non-medical items from a medical aid is a crime.
You must not share your membership card with people who are not members of SABMAS. People usually do this because they want to help someone go to hospital or get treatment. However, since we only budget for our member’s expenses, this kind of fraud means we have to charge more each month, and in the long run this means we have to add more rules to pay out benefits. It is illegal to allow a non-member to use a member’s membership card for any medical treatment.
Most medical aids do not pay for cosmetic surgery because they are optional procedures. It is unlawful to have cosmetic surgery and then claim for it as if it was another kind of operation.
Changing the information on claims
The doctor, specialist or pharmacy must give the member an invoice that shows when the member visited the healthcare provider, what the member was treated for, and the cost of the visit. The medical aid needs this information to pay out claims correctly. It is illegal to make a copy of the claim and change it, or to charge for treatment the member did not receive.
How can you prevent fraud?
- Read your claims statement carefully. Make sure that there are no claims for treatment you didn’t receive
- Make sure the name on your medicine matches the name on the pharmacy’s bill
- Keep your medical aid number and membership card in a safe place
- Don’t accept offers from a healthcare provider to pay you to claim from your medical aid
- Report suspicious behaviour.
Report fraud to your medical aid
Ultimately, fraudulent claims cost you as a SABMAS member as there is less money available to pay for valid claims, potentially resulting in higher contribution increase. If you even slightly suspect someone of committing fraud, report all information to the medical aid fraud hotline. You do not have to tell us who you are to report fraud.
Toll-free phone: 0800 004 500
Toll-free fax: 0800 007 788
Post: Freepost DN298, Umhlanga Rocks 4320.
Or email our fraud department directly to investigate the matter.