Medical Aids

A step closer to the NHI

Health Minister Dr Aaron Motsoaledi says the release of two bills – the Medical Schemes Amendment Bill and the National Health Insurance (NHI) Bill – is poised to make history.

The bills will pave the way for more access to medical healthcare through the NHI.

The Minister was speaking at the policy debate on the Health Budget Vote in the National Council of Provinces on Tuesday.

“On Thursday, I will be releasing two bills to the nation in a press conference – the Medical Schemes Amendment Bill and the NHI Bill.

“This question of universal health coverage, which we call NHI, is not going to leave the world unshaken. This is what we are going to be announcing on Thursday.”

The minister’s announcement follows cabinet’s approval of the two medical bills two weeks ago.

Motsoaledi cited the prestigious British medical journal, The Lancet, which dedicated one of its editorials to universal health coverage, saying it will be “the third transition of health ever since human beings started populating this planet”.

Universal health coverage was adopted by the United Nations as one of the 17 Sustainable Development Goals.

Referring to the NHI as the “land question of health”, Motsoaledi said the debates on the NHI will rage not only in the field of health but in the economic and social lives of the people.

“Yes, under NHI, the rich will subsidise the poor. The young will subsidise the old. The healthy will subsidise the sick. The urban will subsidise the rural.

“For this reason, we are contending that this will be a substantial policy shift. It will necessitate a massive reorganisation of the whole healthcare system, both public and private, and completely change the relationship between our spheres of government,” said the Minister.

According to Motsoaledi, laws will have to receive an overhaul to ensure the success of the NHI.

“We are going to be asking you to change most of the laws that you have painstakingly cobbled together since the advent of democracy.

“You might have had to dismantle some of the relationships between spheres of government and also rattle the corporate world in health.

“That is what we will mean by a massive reorganisation of the health system,” he said.

Amendments to acts to prevent disasters

According to Motsoaledi, disasters in the health sector such as Life Esidimeni, oncology in KwaZulu-Natal and Mediosa, stem from issues such as human resources, financial management, supply chain management and infrastructure maintenance.

“All the major disasters in health that occurred in our country are about these four and the way they are governed and controlled. We have already identified 12 Acts that will have to be amended by this House to accommodate NHI,” said the minister.

The minister said implementing NHI projects using the R4.1bn allocated by the finance minister for cancer, school and mental health will be the next step for his department.

Consider this advice before travelling abroad for health care

I will never forget the first Canadian medical tourist I interviewed. I was gripped when this person told me about travelling abroad for invasive surgery, accompanied by their spouse. While in India, this spouse required emergency surgery to address a chronic condition that had worsened.

This situation sounded so distressing and the researcher in me wondered: Could the mental and physical stress of caregiving in an unfamiliar, international context have negatively impacted the spouse’s health to the point that surgery was required?

There are many reasons why patients opt to seek health care abroad. In some cases, it is because they cannot access timely surgery locally. In others, they are seeking an experimental procedure that is not available at home, such as an unapproved stem cell therapy.

For most of the last decade I have been involved in extensively studying medical tourism. I have spoken with patients, policy-makers, doctors, nurses, tourism officials, travel operators and many others in well over a dozen countries. Much of this research has examined ethical and equity questions related to medical tourism. For example, trying to understand if and how local patients, health-care providers and health systems can benefit from medical tourism in the Caribbean.

One thing I have learned is that many medical tourists do not travel on their own. Many travels with a friend or family member.

Friends and family provide support and companionship. They serve as a source of familiarity and comfort. They can assist with very practical matters, such as confirming travel plans and keeping people at home informed about the medical tourists’ health status. My own research has found that these roles and responsibilities can be quite extensive.

I would like to take a step back and offer a more critical perspective on this practice of informal caregiving by friends and family members in the context of medical tourism.

‘Shadow workers’ in a multi-billion dollar industry

It is often reported that medical tourism is a multi-billion dollar global industry. (Though, let’s be careful not to rely too much on the numbers that are reported because most of the quantitative figures that exist are wrong.)

Clinics, hospitals and entire countries are actively trying to attract medical tourists through costly advertisement campaigns and other promotional efforts. But what about the friends and family who accompany them?

I rarely see a mention of friends and family in the brochures, websites, e-mails and trade shows that advertise medical tourism services.

There is no formal guidance on what they can expect while they are abroad. No formal resources to prepare them to do things like change wound dressings in hotel rooms or navigate airports with someone recovering from surgery.

These friends and family are, in many ways, “shadow workers” in a multi-billion dollar global industry.

The unpaid care work they provide to medical tourists is invaluable. And I have no doubt that many patients would not even consider medical tourism without someone to accompany them on what can be a painful and challenging journey.

Yet, in my opinion, the industry does little to protect them.

Nine factors to consider

I think there are many things that can be done to transition these friends and family members from unpaid “shadow workers” to prepared members of medical tourists’ support networks.

My collaborative research shows that one tangible action is to develop resources to help these individuals make informed decisions, become prepared travellers and caregivers and stay safe and healthy.

I was recently involved, with a research team, in interviewing Canadians who had accompanied a family member or friend abroad for medical tourism. Their stories contained very important pieces of advice for people considering taking on this role. We gathered this advice together and published it in an academic article.

We also put together a simple, one-page information sheet that offers nine specific factors that I strongly urge friends and family to carefully consider before accompanying a medical tourist abroad.

Read, share, discuss

The information sheet we developed can be shared widely. The text can be copied and pasted freely onto the websites or promotional materials of clinics and hospitals seeking to treat medical tourists.

I invite people to read it, share it and talk about the content.

This sheet also serves as a companion to another information sheet we developed —for Canadians thinking about participating in medical tourism.

The global medical tourism industry relies on the unpaid labour provided by patients’ friends and family members. Their unpaid labour needs to be acknowledged. Their needs must be assessed. Their health and safety need to be protected.

The ConversationI push for these things to happen when I meet with medical tourism sector representatives, and I call on others to push for the same.

This article was originally published on The Conversation. Read the original article.

Prioritising the health citizen in UHC

The concept of health citizenship integrates patients’ needs with the knowledge of healthcare professionals in planning tools and programmes that will change the inequalities in healthcare.

Therefore, the 19th annual Board of Healthcare Funders of Southern Africa (BHF) conferencePutting the health citizen first, pushing the boundaries of the impossible – will focus on prioritising the health citizen and how the industry can translate technical evidence and knowledge into policy and action as countries across the southern Africa region begin to progress towards universal health coverage (UHC).

“A lot of research has been conducted in relation to UHC theory and policy evidence, and the implementation will require an inclusive process and for all stakeholders to collaborate in the interest of the health citizen. Our aim for this year’s conference is to map out priority areas for the health citizen and agree on implementable action items to ensure that private sector healthcare industry players across the region proactively gears towards UHC,” says Dr Katlego Mothudi, managing director, Board of Healthcare Funders of Southern Africa (BHF).

Private sector role

“A number of questions remain on how to overcome fragmentation in healthcare as African countries begin to make progress towards this global agenda to achieving access for all by 2030.

“How can the public and private sector scale up information systems and technology infrastructure to create access to health? We need to explore platforms that can be used to hear the voice of the marginalised, how we can incorporate the voice of civil society and business in the discourse? How do we answer to the inevitable consequence of the requirement to scale up quite rapidly as a response to the changing and merging of the two environments?”

According to Mothudi, there are a number of actions that the private sector can already begin to implement as priorities to meet the needs of the health citizen. These interventions can then address specific health challenges, as can the design of scheme benefits that actively improve overall health, risk pooling, cross subsidisation, as a way of enabling defragmentation of systems. Engagements are also required around the concept of strategic purchasing of healthcare services.

Speakers at the conference will include local role players, as well as experts from Egypt, Kenya, the USA, Singapore and Namibia, among others. “We can learn a lot through shared experiences and identifying what has worked in other countries, understanding how those systems have been implemented and adapt learnings to our context,” says Mothudi.

Act could redress medical scheme sustainability issues

Health Minister Aaron Motsoaledi has hinted at a number of reforms that directly address challenges of sustainability that the medical schemes industry is currently facing.

“We know that rising costs in healthcare are outstripping inflation, and legislated steps to address this are overdue. The proposals will usher in a new set of rules for how medical schemes operate,” says Mark Arnold, principal officer of Resolution Health Medical Scheme.

“While the details of how uniform tariffs for healthcare providers will be arrived at are not expected to be addressed in the Medical Schemes Amendment Bill, but rather will be informed by the outcome of the Competition Commission’s Health Market Inquiry, this is an important step towards protecting healthcare consumers.”

He explains that there are no regulations at present to limit what healthcare service providers can charge for their services. “A High Court ruling in 2008 scrapped the National Health Reference Price List (NHRPL), which aimed to institute associated provider pricing ceilings. The NHRPL and Prescribed Minimum Benefits (PMBs) were originally intended to work in tandem to protect medical schemes and their members.

“As it stands, with PMBs remaining in force without the moderating influence of the NHRPL, even the Council for Medical Schemes has noted with concern that healthcare providers tend to charge higher fees for PMB diagnosis and treatment. This is because medical schemes have no choice but to cover the costs of PMBs in full.

“The fact that medical schemes are left to individually negotiate rates with healthcare providers also means that a handful of large medical schemes have considerably more bargaining power than the rest of the industry. The consequence of this is that healthcare providers make up for the discounted rates they have acquiesced to with the large schemes by demanding higher fees of the smaller schemes.

Uniform tariffs

“The proposed introduction of uniform tariffs for healthcare providers will go a long way towards levelling the playing field, however it is imperative that tariffs are applicable to both PMB and non-PMB claims and ICD-10 coding conventions must be clearly defined to avoid practises such as code farming,” he observes.

“At the moment there is no standard for acceptable ICD 10 codes associated with a particular treatment or procedure, and the risk is that if uniform tariffs are introduced without establishing coding conventions, then providers may simply bulk up on ICD codes to achieve higher claims. Medical scheme administrators will therefore need to ensure they have the infrastructure and necessary systems in place to manage this effectively and adjudicate claims based on coding.”

Arnold says that the proposal for a new set of PMBs, which will place greater emphasis on primary and preventative healthcare, could be a welcome development.

“This development would directly benefit members’ health in the long term, as health concerns can be identified and treated before progressing to more serious conditions. For medical schemes, this would also help to avoid more costly treatment down the line.”

Co-payments

One of the proposals reportedly contained in the Medical Schemes Amendment Bill is a prohibition of members being charged co-payments. Arnold explains that under the status quo, co-payments are implemented on non-PMB claims and while schemes limit co-payments as far as possible, these are generally higher for elective surgical procedures.

“Limits on claims for elective procedures are in place particularly where more conservative means of treating the condition, such as physiotherapy, are available. Here the co-payments charged for such procedures are in place to protect the funds available for claims that are truly a medical necessity. Here, co-payment should, in theory, encourage members to consider alternatives to elective surgery.

“If co-payments on elective procedures were to be scrapped, this would open up an avenue of considerable risk for the majority of members in favour of the few. This is because if procedures are covered in full by law, then healthcare providers may be encouraged to prescribe more costly treatment rather than choosing more conservative options that are less profitable.

“The average medical scheme member may welcome the prospect of co-payments being eliminated, however the wider implications must be considered.

“We would, however, instead advocate the introduction of a defined list of treatments that co-payments can be charged for, to protect the funds available to cover the entire membership of any given medical scheme,” he adds.

“The reality is that co-payments are one of the few risk management tools left to medical schemes to counteract over-servicing from opportunistic healthcare providers and undesirable claiming practices from a minority of members who may otherwise abuse the system and reduce the value we can offer to all members,” Arnold concludes.

What the POPI Act means for medical aid schemes

When implemented, the Protection of Personal Information (POPI) Act will fundamentally change the way personal data is managed. Corporate South Africa, including medical aid schemes, insurance brokers, financial advisors, marketers and even brands need to start preparing now for its impact.

“A patient’s medical information and history are particularly sensitive,” says Gerhard van Emmenis, principal officer of Bonitas Medical Fund. “Which means the entire service chain, from medical practitioners to pharmacists, administrators and scheme, involved in receiving and storing this information will be required to meet the stringent POPI requirements.”

Essentially POPI, based on European legislation, outlines eight general conditions and three specific conditions, which will ensure businesses and organisations take responsibility for the way they share personal information, how that data is used and stored and who has access to it. Many countries have similar legislation in place to protect information and this also governs the transfer and sharing of data internationally.

Why the introduction of POPI?

We live in an information-driven world with easy access to data and personal information via the internet, emails, Facebook, Instagram, LinkedIn and more, as well as traditional faxes and written correspondence. With an increase in cyber threats and information being leaked and shared, POPI is making sure businesses – and even individuals – are more careful with personal information and to take responsibility for this data.

The message to the public is that the new Act should be taken very seriously. “Unlawful retention, distribution, sharing or unauthorised use of personal information may result in non-compliance with the Act, which will carry onerous penalties of up to R10m in fines, and could even result in jail sentences (in some instances of up to 10 years), depending on the seriousness of the breach or non-compliance.”

According to Van Emmenis, compliance with POPI is of the utmost importance for all medical funds. “This applies to both members, their brokers and those in the medical fraternity,” he says. “We are ready for its implementation and have taken great care to ensure data protection is a key priority.”

Storing patient information

According to the Health Professions Council of South Africa (HPCSA) recommendations, the most important factor is for stringent precautions to be taken to safeguard patient information. For this reason, when the Council for Medical Schemes (CMS) requested information for the Central Beneficiary Register last year the majority of medical schemes did not comply, mainly due to concerns of how the information will be stored and used.

The concern is that although the rationale behind the Department of Health wanting a Beneficiary Registry in terms of negating fraud and recovering payment for treatment at state facilities, there is still uncertainty around how this information will be stored and used.

The CMS has since clarified that no actual medical data is required and that an Industry Technical Advisory Group task team has been established, with representatives from medical schemes and administrators, to deal with security issues and POPI compliance. Medical aids continue to engage with the CMS to find a workable solution regarding their directive for member information.

Holistic approach to healthcare

“In order to take a holistic approach to medical aid members’ care and preventing duplication of medical tests, we embarked on a campaign in 2016 to obtain members consent to share their personal data with specific healthcare providers,” explains Van Emmenis. “When all co-morbidities are taken into account it ensures that healthcare providers work together in the patient’s best interest.”

Member data and healthcare providers

All healthcare providers who interact with patients are generally permitted to have access to their information to a certain extent. However, to conform to POPI regulations, medical schemes need to ensure claims, medical conditions and treatment are only shared if the member chooses for it to be.

Regarding the implementation of POPI, Van Emmenis says, “we have processes in place to securely store the data we have and are ready for the implementation of POPI and will conform 100% with the final conditions outlined in the Act. Protecting the personal and medical records of our members is a key priority.”

Unhealthy relationship between employee wellness expectations and reality

While many employers recognise the role they have to play in influencing good employee health, most are not employing strategies that best enable these outcomes.

A survey, which covers more than 900 employers across the EMEA region, in 25 industries and covering 2.7-million employees aims to identify the key health issues employers are facing as they develop their people risk strategies, including the opportunities and challenges.

The majority of employers overwhelmingly recognise the importance of having a well-defined, well communicated health and wellbeing programme and that there is a correlation between employee health and their performance, and 100% of South African firms agree that they have a role to play in positively influencing good employee health.

Nearly 70% of overall respondents either have a specific budget in place, or plan to have within the next two years, to fund health initiatives.
Most employers seem to have a good idea of the types of health and wellbeing issues they need to focus on, for example, lifestyle risks, and financial, physical and/or emotional wellbeing. Stress and mental health issues are the primary concern of 72% of South African respondents.

Yet, in spite of this recognition of a correlation between health and employee performance, many organisations do not appear to be implementing strategies that best enable these outcomes, and the prevalence of health programmes of all types is lower than two years ago.

Only 40% of employers say they have a defined health strategy in place, the same as 2016, and even fewer (36%) have a clear view of the impact (including cost) of the health issues in their organisation.

No budget

The key barriers to running or implementing successful wellbeing programmes include having no budget or a budget that is not deemed enough, having limited resources, or not being able to measure the effectiveness of any initiatives.

Only 22% of employers use data to support their health and wellbeing strategy, and just 17% of South African employers measure ongoing success of their health programmes.

Less than 40% of employers rate their health and benefits communication to employees as good.

Top HR issue

The survey also finds that attracting and retaining talent is the top HR issue in 2018, overtaking increasing productivity and employee performance, which has dropped to the number three concern since the last survey in 2016. Improving engagement and morale is the second highest ranked concern.

“In spite of these obvious concerns, South African firms appear less proactive in offering almost all types of health initiatives. Programmes addressing stress and mental health in particular are the least likely to be provided. Putting in place more structured programmes to address this would seem a good investment,” says Gavin Griffin of Aon Employee Benefits in South Africa.

“Although South African respondents are more confident in their health and benefits communications than many others in the survey, low utilisation by employees has jumped into second place when they are asked to rate the obstacles to health initiative success. This is often a symptom of poor or ineffective communications and a review of current communications programmes would be a worthwhile exercise.”

Flu shots on the go with Discovery Health and Uber

With winter and the dreaded flu season around the corner, Discovery Health has teamed up with Uber to provide flu shots on-demand.

For one day only, Wednesday 18 April 2018, riders in Johannesburg, Pretoria, Cape Town, Durban and Port Elizabeth will be able to request UberWellness on their app from 10:00 to 15:00, and will be met by a nurse who will administer a flu vaccine.

On the day, Discovery Health, Clicks and Dis-Chem have partnered to provide nurses who will be able to administer up to five individual vaccinations during one home or office visit. While the flu shots will be free, a once off charge of R100 will be charged directly to the rider’s Uber account to cover the cost of the home or office visit.

Discovery Vitality members will also earn 1,000 Vitality points for having their flu vaccine.

How it will work

  • Open your Uber app between 10:00 – 15:00 on Wednesday, 18 April.
  • Set your ‘pickup’ location.
  • Swipe right on your vehicle options to the UberWellness option.
  • Confirm your ride and if you are successful an accredited nurse will arrive to administer flu vaccinations for up to five people.

T&Cs apply

  • You must be 18 years or older to request.
  • The accredited nurse can administer up to five individual vaccinations at one visit, for a flat rate of R100.
  • Available in selected areas of Johannesburg, Pretoria, Cape Town, Durban and Port Elizabeth.
  • The vaccine will be at no cost to you: you will only pay R100 to cover the cost of the trip when you request through the Uber app.

On the day, demand will be high and as such riders are urged to be patient when requesting. Should riders be unable to request for the flu vaccination on the day, Discovery Health encourages riders to visit their closest healthcare provider or Clicks and Dis-Chem clinic to get their flu vaccination as soon as possible.

Putting the health citizen at the centre of UHC

As healthcare systems worldwide evolve towards universal health coverage (UHC), there must be a move beyond technical policy evidence to an action plan driven by participation, collaboration and implementation, where the overarching priority remains the person receiving the healthcare service

“If we can get that mindset right across the healthcare value chain, we will move closer to achieving UHC. We’ve heard a lot about why UHC would be impossible to implement, what we cannot do, and why we cannot do some of the things. It’s time the industry pushes boundaries to look at what is possible and what can be done to implement those pockets of possibilities without having to change regulations or legislation. It’s about identifying the low-hanging fruits and kick-starting practical steps towards UHC,” says Katlego Mothudi, managing director, Board of Healthcare Funders of Southern Africa (BHF).

Pockets of success

The narrative around introducing and implementing UHC in Southern Africa has always been that it is unaffordable, and that government systems are collapsing and are not geared to delivering UHC. Yet there are pockets of success in countries such as Rwanda, which ranks as one of the most successful UHC programmes in Africa. Lessons can be learned from Ethiopia and Ghana, which have also achieved significant milestones. These examples go to show that UHC for Southern Africa and for Africa is possible, he says.

“First we need to remove the barriers that we have created in our thinking about UHC. We need to look at what can be done now, without waiting for regulatory reform, and push the boundaries of what we have deemed impossible to realise workable solutions in delivering UHC.

Changing the relationship between the health citizen and service providers

“The healthcare sector’s priority should be ensuring that healthcare delivery is more member-centric and not service provider focused. Efforts must be made towards ensuring that the end product delivered to the health citizen meets their healthcare needs,” says Mothudi.

The relationship between healthcare service providers and the health citizen has conventionally been transactional. Even with chronic health citizens, healthcare service providers have built a relationship of dependence.

According to the BHF, there is a lot that medical schemes can do, working together with governments across the region, without having to wait for regulatory reform to begin driving the implementation of UHC.

Some of the current challenges include cost escalation, reduced access and poor or non-standard quality of care. For the insured, without a doubt, medical aid contributions required to purchase healthcare are very high, and out-of-pocket payments are increasingly becoming a big challenge to the health citizen. Benefits schedules are also so complex that members don’t know benefits to which they are entitled.

A common view among the insured is that while contributions are high, there aren’t enough benefits to justify the costs. For the uninsured, of concern across the region is adequate access to healthcare services as well as the quality of healthcare received. Across the board, health citizens do not know what to expect from their healthcare providers, and also don’t know how to measure quality care. As a result, they cannot benchmark to determine whether they are receiving the best available healthcare services or not.

Information and a multidisciplinary approach

“There needs to be adequate consultation and informed consent to empower the health citizen with appropriate information to influence their choices and compliance to the healthcare services provided to them.

“Information prioritisation must focus on empowering the health citizen; there is a need to create awareness of the drivers of costs, cost of services, to create an understanding of the impact of fraud on the health citizen, the impact of choice of care, as well as an understanding of treatment modalities.

Across the region and continent, there is inadequate accountability for the quality of healthcare. New technologies come into the country and into the region unvetted. There is a lack of standardisation of healthcare measures, which raises the question: whose interests does the healthcare sector seek to serve? If it is for the healthcare citizen, we would be more cautious about these things. A multidisciplinary approach to healthcare delivery and regulation alignment will enable a seamless implementation of universal healthcare across the continent.

“This can only be attained through industry collaboration with all the stakeholders in healthcare to truly deliver to the needs of the health citizen,” says Mothudi.

Putting the healthcare citizen first, pushing the boundaries of the possible is the theme of the upcoming 19th Annual Board of Healthcare Funders of Southern Africa Conference, which will be held at Sun City, from 17-20 June 2018.

Success in the fight against fraud, waste and abuse

‘Fraud, waste and abuse (FWA) in the healthcare industry is one of the main drivers of healthcare inflation and increased costs,’ says Kenneth Marion, Chief Operating Officer of Bonitas Medical Fund. ‘It’s a key focus area for us and we’re pleased to report that we’ve made great strides in the fight against fraud, waste and abuse. In fact our identification and confirmation of FWA has increased to over R129.8m in 2017 compared to R79m in 2016.’

The price healthcare pays

The local private healthcare industry spent over R150bn in 2016. Of this, a staggering
10%–15% of claims contained elements of fraudulent information – adding an estimated R22bn to the annual cost of private healthcare.

‘Over the years, we have observed an increasing trend in the abuse of the member’s benefits by certain medical service providers and fraudulent claims as a result of collusion between medical service providers and, in some instances, members of the Fund. This behaviour undermines the financial sustainability of the Fund and is detrimental to all of its members,’ Marion explains.

Who is affected?

Because a medical scheme is a non-for-profit organisation healthcare fraud, waste and abuse has a direct impact on the membership base.

Examples of FWA

Waste and abuse are far higher than fraud and more easily quantifiable in terms of values as it is usually a clear contravention of tariff codes or a rule that exists. The most common practices include:

  1. Billing for services not rendered (over billing).
  2. Using incorrect codes for services (at a higher tariff).
  3. Waiving of deductibles and/or co-payments.
  4. Billing for a non-covered service as a covered one.
  5. Unnecessary or false prescribing of drugs.
  6. Corruption due to kick- backs and bribery.

Combatting fraud

‘To minimise the impact of these common practices and to some extent address it, we have adopted a zero tolerance approach to FWA,’ says Marion.’ In 2015 we introduced an analytical software programme to identify anomalies or irregularities that could be indicative of FWA. The software is a robust solution that detects irregular claiming behaviour both for claim types and service providers.’

The successes

During 2017, Bonitas’s activities to detect and clamp down on FWA were amplified, with excellent results.

Total quantified value for interventions R129.8m (2017) R79m (2016)
Waste and Abuse Recoveries R35m (2017) R22m (2016)
Fraud recoveries R3,006,189 (2017) R2,096,381 (2016)
Total of recoveries R38m
Total paid by the Fund R47,05,686 (October 2017)
Decrease in claiming behaviour of identified healthcare providers R75m in 2017 (R31m 2016)

Bonitas investigated 35 cases of healthcare providers submitting fraudulent claims

These cases were reported to the South African Police Services (SAPS) and Specialised Commercial Crime Unit and criminal cases subsequently instituted. Five cases were finalised and all five healthcare providers were found guilty of fraud.

The sanctions applied include, but are not limited, to:

  • Laying criminal charges with SAPS against the perpetrators
  • Reporting the medical service providers to the relevant medical regulatory bodies
  • Application of section 59(2) and (3) of the Medical Schemes Act against the medical service providers;
  • Taking civil action against the perpetrator, and
  • Termination of membership where necessary.

Finding the culprits

The majority of healthcare providers implicated in the reported criminal cases are speech therapists and audiologists. Four of the convicted healthcare providers were medical technologists from Limpopo who submitted false claims for services which were never delivered. They were charged with 180 counts of fraud, made up of 21,171 claims. Bonitas is constantly engaging with the police and the crime unit to ensure progress on these cases.

Re-couping losses

One healthcare provider, practicing as a GP, was also found guilty of fraud after he pleaded guilty to the charges against him. This healthcare provider was also submitting claims to Bonitas members for services not rendered and using a locum that was not registered with the Healthcare Professions Council of South Africa. The provider was sentenced to five years imprisonment which was suspended and a fine of R185,000 payable to Bonitas by 31 January 2018. In addition, 52 healthcare providers were reported to Health Professionals Council of South Africa.

The punishment

Three of these providers are serving prison sentences of 9-10 years while one received a suspended sentence. Another provider is awaiting sentencing. The remaining 30 criminal cases are at various stages in court.

In 2017, Bonitas updated the forensic detection software to detect irregular claims at pharmacies as well. This resulted in:

  • A 40% increase in identified fraud, wastage and abuse
  • Recoveries increasing by 85%
  • A positive change in claiming patterns from healthcare providers a behavior change that amounted to R75m as of September 2017.

Recovering the money

Steps were taken to recover the money Bonitas paid out to these providers as a result of their fraudulent behaviour. Various measures were taken against healthcare providers who failed to honour the repayment terms. This includes internal controls introduced to identify healthcare providers who evaded the sanctions imposed, consequences of defaulting including being blacklisted.

The challenges

One of these challenges was a healthcare provider signing an acknowledgement of debt, agreeing on a pay back installment and then defaulting. A process was therefore initiated where the healthcare practitioner would be informed of consequences of not honouring the agreement which included them being blacklisted.

‘In some cases, blacklisted healthcare providers, who had their practice numbers barred by Bonitas, would simply acquire new practice numbers and come back to the system.’ says Marion. ‘This prompted us to introduce manual screening of all new practice numbers. This process has yielded positive results as 63 healthcare providers who were trying to circumvent the sanctions have been identified and blocked. We also introduced a process where a healthcare provider with an outstanding amount will be blacklisted in the credit bureaus.’

Zero tolerance

‘Based on our zero tolerance approach with regards to FWA, similar sanctions are being applied where medical service providers and/or members have been identified as having been involved. The sanctions are applied subject to the merits of each case,’ explains Marion.

‘This year we will continue to build on the criminal successes we have realised in 2017 and take further strides to conquer fraud, waste and abuse while constantly enhancing the working relationships with all stakeholders.’

Join the fight against fraud

Follow these tips to help combat fraud, waste and abuse.

  • Keep your personal medical scheme membership details (such as your membership number) private and your membership card safe
  • Check your medical aid statements to make sure that all claims are correct and for services you actually receive
  • Avoid any activities where you receive cash back for providing your membership details or other benefits that are not in line with the stated benefits on your option
  • Do not hesitate to query any irregularities relating to your claims with the call centre
  • Report any suspicions of fraud to our Fraud Hotline on 0800 112 811 – you can remain anonymous

Marion says, ‘We have systems in place to identify FWA within Bonitas but we also appeal to anyone who suspects any kind of wrongdoing to report it to their medical aid immediately.’

VAT increase won’t impact on medical aid contributions

There has been much debate around the 1% value-added tax (VAT), its impact on consumers and just how this will affect the money left in their pockets at the end of the month. With the revised general fuel levy, it’s clear that consumers will have to tighten their belts and adhere to stricter budgets.

The rising costs of healthcare

One area of concern is the cost of private medical aid and VAT. For years increasing healthcare inflation and economic pressures have been a challenge for the industry. “The reality is that when consumers are struggling, medical aid, which is essentially a grudge purchase, is often viewed as unaffordable,” says Gerhard van Emmenis, principal officer of Bonitas Medical Fund. “In addition healthcare costs are not regulated which is why it is crucial for medical aid schemes to continue to explore ways to contain costs without compromising the level of health care offered to members.”

Members’ contributions

However, he says, because the 1% increase will not impact monthly contributions or annual benefits. “Many members are confused as to whether VAT is payable on medical aid contributions but let me reassure you it is not,” says Van Emmenis. “The VAT increase will have no effect on members directly and what they pay every month. Medical aid contributions for 2018 are already. So, while the increase in VAT may influence the price of services, it will not impact benefits.”

“If your plan covers you at 100% of a scheme’s rate, you are still covered at 100% of that rate, no matter what the cost to the scheme because the scheme will absorb the VAT when paying for member’s benefits. The only impact is when it comes to savings and day-to-day benefits with members having a 1% lower buying power.”

The Council for Medical Schemes

In fact, changing contributions in the middle of the year can only be done with the permission of the Council for Medical Schemes following a request from the trustees of the medical scheme. This is a rare occurrence and most schemes generally put through contribution increases in January each year.

The law

VAT is never the property of any private entity but belongs to the government. “We are therefore only vendors that collect the monies on their behalf. From April 1, we will increase the VAT to all providers of the scheme by 1%. However, although this will have a direct impact on the budget for 2018 it will be absorbed by operational surpluses and not passed on to members.’

Tax credit

One positive announcement out of the budget speech regarding medical aid was around tax credits.

“Medical tax credits are effectively used as an ‘expense’ when calculating tax and reduces the amount of tax payable by a household belonging to a medical aid,” says Van Emmenis. ‘There are eight-million people who rely on these credits to make medical aid more affordable. Speculation was rife that the tax credit would be removed but it is a relief that private medical aid members have some reprieve.”

The bottom line: The 1% VAT increase and the additional 52 cents general fuel levy will have a knock-on effect for South African consumers, things will cost more. However, it will not affect monthly medical aid premiums or member benefits although it will have an indirect impact in terms of healthcare services being more expensive, which will reduce buying power.