The establishment of standards for South Africa’s private healthcare sector to effectively deal with fraudulent activities – including fair sanctions for convicted fraudsters – as well as the creation of a structure to continuously deal with the issue of fraud, waste and abuse in the industry, are among the priorities set for the Fraud, Waste and Abuse Summit to be convened by the Council for Medical Schemes at Sandton Convention Centre next week (28 February to 1 March).

The CMS objective is to bring together medical schemes, administrators, managed care organisations, policy makers and other stakeholders to discuss strategies for dealing with fraud, waste and abuse in the industry.

 “The intended outcome of the FWA Summit is to get stakeholders to sign an industry charter as a pledge to combat fraud, waste and abuse in the private healthcare sector,” CMS acting registrar, Dr Sipho Kabane, explains in the most recent Summit media announcement.

Specific practices to be addressed – practices said to be costing the industry more than R22 billion a year – will include over-billing for services or supplies, falsifying patient data to obtain payments from medical schemes, referring patients to specific specialists or hospitals in return for kickbacks, as well as misrepresenting diagnoses and miscoding of claims to obtain payments or more money than justified.

“All healthcare stakeholders, including medical scheme members, healthcare providers and professionals, as well as the law enforcement authorities,” Kabane adds, “have a significant role to play in combating this growing challenge. The Summit, therefore, will provide stakeholders with the opportunity to share best industry practices in reducing fraud, waste and abuse in order to close the loopholes and significantly bring down the cost of fraud, waste and abuse.

“Our aim, as an entity mandated to protect the interest of members of medical schemes in terms of the Medical Schemes Act, No. 131 of 1998, is to ensure the stability and financial sustainability of the healthcare industry.

“Fraud, waste and abuse,” the acting registrar concluded, “must be effectively and urgently addressed to stop the ripple effects these could pose to the NHI.”

*Registration and further details available from Pulane Molefe at +27(0) 12 431 0512 or at p.molefe@medicalschemes.com