Criminal networks are targeting your medical aid rands but could you be part of the problem too?
Criminal syndicates and unscrupulous doctors may be defrauding the private health sector of millions as experts warn that medical schemes may reach a breaking point.
“The health care sector is being targeted by criminal syndicates and even devious practitioners. It is a direct threat to the financial viability of medical schemes in the country, including any National Health Insurance initiative we attempt,” says medical advisor on healthcare forensics at medical aid administrator and risk management service, Medscheme Gregory Pratt. Pratt was speaking at the Board of Healthcare Funders Southern African Conference this week in Cape Town.
“The affordability of medical schemes in the country will soon reach a tipping point.”
In 2013 alone, Discovery Health recovered R300 million in fraudulent claims alone – a number that in 2014 CEO Jonathan Broomberg told Continue reading…
On Tuesday, the Constitutional Court ruled that all funds paid by members to their schemes should be considered as assets, regardless of their intended use.
Genesis medical scheme has won its legal battle with the Council of Medical Schemes over how to account for the funds in members’ medical savings accounts (MSAs), a development that has potentially far-reaching implications for both the industry and consumers.
This technical accounting point will make a material difference in the way schemes calculate their solvency ratios that measure gross income against reserves.
Treating MSA balances as assets means schemes’ reported solvency ratios will improve, because funds accumulated in MSAs will now be considered as part of a schemes’ reserves, said Insight Actuaries joint CEO Barry Childs.
This is important because better solvency ratios mean less pressure on schemes to increase premiums.
The judgment overturned a high court ruling that the council has us Continue reading…
The medical aid industry is known for confounding consumers with all sorts of complex terms. Among the most confusing of all are references to medical aid, or medical scheme, rates.
Schemes and plans are quoted as covering the costs of in-hospital procedures up to 100%, 200% or 300% of the scheme rate or tariff. You might reasonably think this means that medical aid will cover all healthcare expenses, up to 100% or more. However, this is far from the case.
In this article, we focus on medical aid rates, how they’re calculated and what impact the different tariff options have on medical aid members. The truth about medical tariffs
Medical expenses in South Africa are not regulated. Doctors, specialists and hospitals can charge what they want, provided the fees are deemed to offer “fair value” to the consumer.
The Department of Health has, however, published a list of recommended tariffs pertaining to specific treatments and procedures conducted i Continue reading…
If GPs are contracted in to a medical scheme network, they might be pressurised to recommend cheaper treatment options and medications, say SA health bodies.
The Board of Healthcare Funders (BHF) and the IPA Foundation (IPAF) is extremely concerned at the comments made recently by the Health Professions Council of South Africa concerning Designated Service Providers (DSPs).
The HPCSA recently released a statement to the effect that healthcare practitioners should be cautious when concluding designated service provider (DSP) agreements with medical schemes as the medical schemes attempted to reduce costs by applying pressure on practitioners within a DSP network to prescribe medication or recommend treatment options, when other more appropriate, albeit more expensive, options were medically indicated and readily available.
Pushing healthcare costs down
In the current environment where there are no regulated tariffs for healthcare procedures, Continue reading…
Medical cover is expensive, and getting more so every year. Unfortunately this could mean we opt for lower monthly premiums that could mean you aren’t covered in the event of an expensive procedure.
The South African Society of Anaesthesiologists (SASA) is advising South Africans to consider the multiple factors affecting cover when choosing access to medical care.
The SASA understands that healthcare is often hard to comprehend and expensive to access. As a result, the Society believes, many consumers choose their medical plans – including how much cover it offers and whether care is provided at public or private institutions – based on the principle of “what can I afford monthly”.
“The truth is, most people look at cutting their medical costs in an effort to reduce their household spend when they feel an economic pinch. This is a difficult decision, since we’d all like to have access to the best facilities and treatment with the least out of pock Continue reading…
To obtain optimal value from your medical scheme plan, it’s critical to fully understand the scope of benefits it offers and to manage those prudently.
To obtain optimal value from your medical scheme plan, it’s critical to fully understand the scope of benefits it offers and to manage those prudently. It’s an especially important consideration during the winter months. This is according to Dr James Arens, clinical operations executive at Pro Sano medical scheme.
Minor ailments like a recurrent common cold, for example, may not necessarily require repeated doctor visits that could potentially use up benefits that might be more appropriately used elsewhere.
Dr Arens points out that the economic climate in recent years has seen many South Africans downscaling on their lifestyles.
“This often means ‘buying down’ when it comes to medical scheme cover. It’s understandable that when money is scarce, people wish to pay as little as possible while sti Continue reading…
Are your health insurance costs too high? Try decoding your medical aid terms and conditions and associated costs to make sure that it works for you.
“While health insurance is important, it comes at a cost that is rapidly rising. Unfortunately for the consumer, this affects medical scheme membership contribution rates, and the increases of which are sometimes significantly higher than general inflation.
As schemes try to contain their costs in the face of increasing claims, they make changes to their plans and benefits, which can come as a surprise to the consumer,” says Mark Payne, CEO of the Independent Community Pharmacy Association (ICPA).
Annual review of your plan
He recommends that an annual review of your plan is absolutely vital, and will affirm that it is serving your needs rather than the other way around.
The ICPA advises on several important things you should look at when considering a new medical scheme or reviewi Continue reading…
The medical scheme industry is full of jargon and benefit structures that often leave the man on the street confused and frustrated when it comes to understanding and accessing their benefits.
Medical schemes have in recent times attempted to simplify terminology to make it more understandable, but are they doing enough to ensure members know what they are paying for?
A recent survey among Resolution Health Medical Scheme (Resolution Health) members revealed that 87% of respondents felt that they generally understood the benefits they were entitled to on their specific benefit option, while 13% said that they found their benefits more than a little confusing.
This is a worrying statistic says Mark Arnold, Principal Officer of Resolution Health, as it means that a large number of members are not receiving advice from a healthcare broker when it comes to choosing their healthcare option, and may lead to members not having the level of cover they need.
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 Continue reading…
Hospitaalplanne, omvattende dekking, netwerkopsies . . . Besluit watter opsie vir jou die beste is. As jy lid is van ’n mediese fonds, het jy tot 15 Desember kans om jou voordeleopsie vir 2018 te verander. Oorweeg jou gesin se omstandighede: Hoeveel is julle; hoe is jul gesondheid; wat kan jy bekostig? Besluit dan watter.. Continue reading…
The world of medical schemes in South Africa is a very different one to 25 years ago. There are strict rules and regulations governing the industry, there to protect both the members and the financial sustainability of the scheme. Now is the time of year when medical schemes announce their annual increases and benefit changes… Continue reading…
Die brood het gekrimp, maar ons betaal nou meer daarvoor. Só het ’n ekonoom die verhoging van meer as 13% in selfbetalings deur mediesefondslede die afgelope jaar beskryf. Verbruikers wat elke jaar swaar trek aan die premies vir hul mediese fondse het boonop nog verlede jaar R29,7 miljard uit hul eie sak opgedok. Dit is.. Continue reading…
Criminal networks are targeting your medical aid rands but could you be part of the problem too? Criminal syndicates and unscrupulous doctors may be defrauding the private health sector of millions as experts warn that medical schemes may reach a breaking point. “The health care sector is being targeted by criminal syndicates and even devious.. Continue reading…
On Tuesday, the Constitutional Court ruled that all funds paid by members to their schemes should be considered as assets, regardless of their intended use. Genesis medical scheme has won its legal battle with the Council of Medical Schemes over how to account for the funds in members’ medical savings accounts (MSAs), a development that.. Continue reading…