Managing your claims - be alert
LIBCARE pays millions in member claims every year. These claims are funded by the contribution income that you as a member make to the Scheme. Fraud can significantly reduce the amount available in the Scheme to pay your claims, and also causes your contributions to be higher to cover any losses and the costs to the Scheme of maintaining fraud management processes.
LIBCARE subscribes to a whistle blowing approach which advocates the principles of the South African Protected Disclosures Act, 26 of 2000. Therefore, in terms of this approach, all whistle blowing reports are treated as confidential. LIBCARE has a zero tolerance approach to fraud.
You play a vital role in ensuring that the funds in your medical scheme are not subject to fraud.
Understand the claims process and check your claims
Members and dependants obtain the health service they require in accordance with their benefits, and the service provider or the member submits the resulting claims to LIBCARE. The Claims Department receives, assesses and approves payment of valid claims subject to LIBCARE rules and your available benefits.
To find out more about how to submit and check your claims for the required details, see page 31 "How to Claim". Also, keep your membership card safe and your medical scheme details confidential.
What is LIBCARE doing to protect my benefits?
Claim alerts have been implemented to ensure that all members have sight of claims which have been received against their membership before they are processed for payment. These alerts can be distributed by email or SMS, if we have your current details on our system. We would like to encourage you to register for this service. You need to check your claims statement thoroughly for any irregularities.
Types of fraud
Medical aid fraud is one of the largest and growing problems that we are faced with in South Africa, as it contributes to the overall high cost of healthcare and occurs at all levels. The healthcare industry has identified the sources of fraud as including:
- Members and dependants
- Healthcare providers
- Employees of medical scheme administrators, and
- Other parties (e.g. non-members, or through cyber means).
Examples of types of fraud committed by these sources:
- Manipulating duplicate claims.
- Billing for services not provided.
- Cash arrangements - for example, healthcare providers handing out cash to members for submitting a claim to the medical scheme.
- Dispensing merchandise to patients - for example, Pharmacies dispensing groceries to members and then claiming for medicine from the medical scheme.
- Provider syndicates sharing members' numbers and submitting false claims for members never consulted with
- Billing for brand name medicine while providing the member with cheaper generic medicine.
- Altering or tampering with prescriptions by pharmacies - for example, two types of medicine are prescribed, recorded on the script and dispensed. The pharmacy enters two additional types of medicine on the script and claims for more.
- Re-submitting claims that have been rejected previously, for example changing the claims information on rejected claims and re-submitting until these meet the scheme rules and are paid.
- Kickbacks - the healthcare provider receiving cash paybacks for referring patients to a specific hospital or healthcare provider.
- Charging more than once for the same service.
- Claiming for services already paid.
- Dispensing sunglasses but claiming for optical lenses or contact lenses.
- Over servicing, for example, the healthcare provider requests patients to come back for a follow up visit unnecessarily.
- Using invalid tariff codes
- Inflating of claims.
- Billing for different medicine package sizes to that dispensed.
- Disguised treatment.
- Dispensing excessive quantities of medicine.
- Medical scheme card fraudulently used - for example, a member lending out his medical scheme card to family members or friends who are not registered to use the benefits of the medical scheme.
- Collusion with other parties to defraud the medical scheme.
- Abuse of benefits.
- Fraudulent foreign claims.
- Enrolling or maintaining the registration of ineligible dependants.
- Failing to notify the scheme when a member/dependant is no longer eligible to remain registered.
- Dual membership, e.g. member or dependant belonging to more than one medical aid scheme at the same time.
- Non-disclosure of prior ailments/treatment on an application form.
- Disclosure of incorrect or misleading information on an application form.
If you suspect any fraud has been committed, report it to Libcare's confidential Fraud Hotline 0800 004 500