Bonitas Medical Fund has entered into a partnership with Helios IT Solutions and international analytics software company FICO in an effort to fight against healthcare fraud.
The FICO solution uses an automated data driven approach which, through advanced predictive analytics and workflow models, is able to detect irregular claiming behaviour at both claim and service provider levels, says Bonitas.
FICO developed the software which has been licensed to Helios IT Solutions.
Fraud wastage and abuse of medical aid benefits is a serious challenge that seriously hampers efforts to solve one of the biggest challenges facing our country - providing affordable, quality healthcare to all South Africans, says Bobby Ramasia, principal executive officer at Bonitas Medical Fund.
He points out in terms of monetary value, healthcare fraud is one of the fastest-growing and leading crimes in the country, adding it is also the most complex form of financial fraud to detect, monitor and prevent.
According to the Healthcare Forensic Management Unit of the Board of Healthcare Funders of Southern Africa (BHF), at least 7% of all medical aid claims in South Africa are fraudulent and the figure could be as high as 15%.
Bonitas says as fraud becomes more prevalent and sophisticated, so must the methods used to combat it.
Medical aid claims amounted to R124 billion in 2014 which means that fraud, abuse and wastage are potentially costing medical aids between R9 billion to R19 billion a year. That adds between R192 and R410 per month to every principal member's medical aid contributions, notes Bonitas.
According to Discovery Health Web site, fraud remains a major challenge in SA healthcare. In 2013, through advanced analytics and big data technologies, the company recovered R250 million in fraudulent claims, it states.
The fraud recovery was enabled by an accelerated analytics landscape built by Discovery Health, in partnership with BITanium.
"Fighting fraud is one of Bonitas' top priorities and, in collaboration with our auditors, we have put a series of measures in place to ensure that the scheme is fraud resilient," the company says.
Bonitas is working closely with the BHF's Healthcare Forensic Management Unit and use a specialist forensic investigation company to conduct investigations, says Ramasia.
The company says it also has a whistle-blowers facility on its Web site to help fight fraud.
Because fraud occurs at all levels along the healthcare delivery chain and involves employees, it is a mammoth task to scrutinise every claim for potential fraud and then to follow up every case, notes Ramasia.
Ideally the healthcare industry needs an integrated approach to fraud which involves all stakeholders - medical aids, healthcare professional bodies, healthcare professionals, the National Department of Health and the regulators, he explains.
The Board of Healthcare Funder's Healthcare Forensic Management Unit is making progress in this area, he adds.
Perpetrators or potential perpetrators must be aware that the likelihood that they will be caught is increasing exponentially due to the advances in technology, warns Ramasia.
"Although we have all these tools in place, one of the most effective ways to combat fraud is still to be vigilant.
"If members are approached by a healthcare service provider to commit fraud, they should also make use of the whistle-blower facility. It is completely confidential so there is no risk."
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