Exploring fraud mitigation strategies in South African medical scheme claims

Abstract

In South Africa, medical schemes contribute substantially to the funding of healthcare. Most of the private healthcare services are accessed through medical schemes. Given the huge amount of money that is spent on healthcare, there is a lot of exposure to fraud in claims submitted to medical schemes. The purpose of the study was to explore strategies to assist in mitigating fraud in South African medical scheme claims. Data was collected at the premises of the medical administrator selected in the case study. A qualitative research methodology was followed in conducting this study. A purposive sample of 15 study participants was selected from the administration company that was chosen as a case study. The results of the study showed that various strategies can be implemented, including establishing a fraud policy and regularly identifying known or unknown trends in fraudulent claims. The identification of these trends can be detected manually and with the aid of technology. Furthermore, implementing appropriate preventative and corrective control strategies can help to curb fraud in medical scheme claims. Collaboration within the medical scheme industry and with other stakeholders will strengthen the fight against this type of fraud. A comprehensive approach should be followed to mitigate fraud in medical scheme claims. Applying the recommendations from the study could assist the medical schemes to reduce the amount of money spent on fraudulent claims, thereby improving their financial viability and reducing the rate of increase in medical scheme contributions for their members.

Keywords: South Africa, medical schemes, fraud, mitigation strategies, claims.