Some of the most significant contributors to soaring healthcare costs are fraud, waste and abuse. These are difficult to detect, monitor and prevent because the perpetrators are at every level of the delivery chain from healthcare providers at the top to policy holders at the bottom with many abusive acts playing out under the radar, for months, even years.
“It is estimated that healthcare fraud costs the sector between 5% and 15% of total pay-outs,” says Lynette Swanepoel, healthcare and insurance forensic specialist at the SA Fraud Prevention Services (SAFPS).
“Fraud is definitely a serious element, but on top of that the healthcare industry also has to contend with waste and abuse of benefits,” she says. One example of healthcare fraud is collusion between the policy holders and healthcare service providers such as doctors and pharmacists, where some doctors or pharmacists will supply non-covered items such as toiletries and baby products, falsely clai