Understanding the types of fraud in claims to South African medical schemes

Background. Medical schemes play a significant role in funding private healthcare in South Africa (SA). However, the sector is negatively affected by the high rate of fraudulent claims.Objectives. To identify the types of fraudulent activities committed in SA medical scheme claims.Methods. A cross-sectional qualitative study was conducted, adopting a case study strategy. A sample of 15 employees was purposively selected from a single medical scheme administration company in SA. Semi-structured interviews were conducted to collect data from study participants. A thematic analysis of the data was done using ATLAS.ti software (ATLAS.ti Scientific Software Development, Germany).Results. The study population comprised the 17 companies that administer medical schemes in SA. Data were collected from 15 study participants, who were selected from the medical scheme administrator chosen as a case study. The study found that medical schemes were defrauded in numerous ways. The perpetrators of this type of fraud include healthcare service providers, medical scheme members, employees, brokers and syndicates. Medical schemes are mostly defrauded by the submission of false claims by service providers and syndicates. Fraud committed by medical scheme members encompasses the sharing of medical scheme benefits with non-members (card farming) and non-disclosure of pre-existing conditions at the application stage.Conclusions. The study concluded that perpetrators of fraud have found several ways of defrauding SA medical schemes regarding claims. Understanding and identifying the types of fraud events facing medical schemes is the initial step towards establishing methods to mitigate this risk. Future studies should examine strategies to manage fraudulent medical scheme claims

Patient Identification and Hospital Information Management Systems in Sub-Saharan Africa: a Prospective Study in Rwanda and Burundi

For many sub-Saharan health facilities; accurate patient identification remains a challenge. Poor national person identification systems; inefficient identification procedures; the use of weak search criteria and sometimes fraudulent practice consist some of the underlying causes. In this study; patient identification effectiveness has been compared between 27 sub-Saharan hospitals using paper based procedures and 6 health facilities in the same region that had implemented a hospital information management system. Based on a simple metric; results show a significant (p0.001) improvement reducing identification errors from 64.6 before to 2.3 after information system implementation in a sample of 1 private and 5 public hospitals in Rwanda and Burundi