The conference of the Board of Healthcare Funders (BHF) has heard that lack of collaboration among medical schemes remains a challenge to fraud management within the sector.

The 20th annual BHF conference is taking place in Cape Town.

CEO of Insight Actuaries and Consultants, Barry Childs says about 20% of medical aid payouts are lost to fraud, waste and abuse.

Childs says medical schemes are resistant to sharing information.

“A practitioner billing one medical aid scheme R2 million a month at scheme rates, it’s just not feasible in terms of the number of hours a day. Even if you’re eating bar ones, the issue is the patients aren’t there. They can’t be there. We’ve heard of syndicates where membership cards get dished around and systems are set up where medical aid administrators are billed automatically for patients that aren’t there. Some of this comes out on whistleblowing because the patient might get a feedback from the medical scheme .”

American health system

The director of a US-based private medical scheme says the American health system only improved marginally in the nine years since Obamacare was introduced.

Speaking at the annual conference of the Board of Healthcare Funders in Cape Town, Torrie Fields from Blue Shields in California warned that with more and more elderly, disabled and poor people accessing the American version of universal healthcare, the perfect storm is approaching.

“More of our population has access to universal health coverage now. I did not say they are getting better care, and that there is a perfect storm at this point in the US delivery system. We have 10 000 individuals who are turning 65 everyday. We have an ageing population and not enough of an millennial workforce; in addition we have people living longer and we have a considerable rise in chronic disease.”