Fraudulent claims bleed medical aid schemes of over US$1,48m

AN estimated US$1,48 million has been recovered from medical aid fraudsters following the adoption of anti-fraud interventions by the Association of Healthcare Funders of Zimbabwe (AHFoZ) as part of efforts to enhance transparency and accountability in the sector.

The funds were recovered in 2022, a period in which healthcare fund members collectively paid more than US$164 million towards settlements of claims by clients.

Medical aid fraud is a contentious issue and for a long time, most societies have suffered in silence for fear of reputational damage once the matter becomes public. Last year CIMAS Medical Aid Society was reported to have been hit hard by medical aid fraud amid claims that one local pharmacy generated 477 fraudulent claims and received millions of dollars for medication that was never dispensed.

Industry experts have said this was the tip of an iceberg on what is happening in the sector. In some cases, corrupt syndicates involving pharmacists and doctors would generate fraudulent medical aid claims and receive money for services not rendered.

Others went to the extent of attending to patients and providing them with medication but asked them to pay a huge shortfall although there was no shortfall or only a small one. After receiving the huge ‘shortfall payment’ the medical aid fraudsters claim the full fees from medical aid societies. Effectively, the service providers end up receiving payments twice for the same service.

In some instances, medical aid subscribers would connive with pharmacists and doctors to obtain prescriptions for drugs for friends and relatives who are not beneficiaries of the medical cover.

The police are on record warning perpetrators involved in such criminal behavior following the arrest of a director of a pharmaceutical company based in Masvingo and a pharmacist over the CIMAS medical aid fraud case.

In a statement ahead of the 14th AHFoZ annual all-stakeholders conference, which begins here today, AHFoZ chief executive Mrs Shylet Sanyanga said medical aid fraud was a serious matter that must be ruthlessly dealt with.

It is for this reason that AHFoZ has introduced a Risk Monitoring System that has helped protect contributors’ money from abuse. This has been buttressed by serious engagements between AHFoZ and healthcare provider groups on the need to conduct thorough audits and uphold professionalism.

“AHFoZ adopted a zero tolerance to fraud and recently introduced a Risk Management Portal to facilitate real-time reporting ‘Fraud Waste Abuse’ cases and an estimated US$1,48 million was recovered in 2022,” said Mrs Sanyanga.

“Furthermore, funders are expected to conduct annual audits, and annual general meetings, and should share audit reports with their contributing members as well as submit the reports to the regulator among other things.

“The engagements will continue for the benefit of the health citizens.

AHFoZ further noted that its members will continue to work closely with the Government to ensure support towards the provision of quality healthcare services to approximately 1,67 million subscribers, which translates to about 11 percent of the population.

“Medical aid societies still account for 80 percent of healthcare service providers’ income. In the year 2022, AHFoZ members collectively paid approximately US$164.6 million towards claims settlements,” she said.

“The biggest slice of claims expenditure went to medicines, accounting for 18 percent, followed by in-hospital fees and general practitioners at 17 percent and 10 percent respectively.”

Mrs Sanyanga also urged members to abide by international best practices to promote good governance practices, which demands that 80 percent of contributions received should go towards claims settlement, 15 percent towards administration and five percent should be channeled towards statutory reserves.

She observed that despite the challenging macroeconomic environment prevailing in the country, the healthcare finance sector has remained resilient.

Meanwhile, Vice President Dr Constantino Chiwenga is expected to officiate at the event, which will run under the theme: “Health at turning point.”

According to a preliminary programme, the conference starts today with an innovation workshop focused on continuous professional development for all stakeholders in the healthcare supply chain and excellent networking opportunities.

Discussions will also cover the economic outlook looking at implications for the healthcare sector this year and beyond as well as the policy direction.

There will also be engagements on the value of the health sector workforce and the role of medical aid.

This year’s programme includes a healthcare innovation workshop and an enhanced awards ceremony with entries from both funders and service providers.

The awards will recognise excellence in different categories including innovation, corporate social responsibility, customer care, environmental, social, and governance. —chronicle