Some medical practitioners in fraudulent claims

Fraud, waste and abuse have recently emerged as the major challenges affecting the medical aid companies while the medical aid schemes seem to be struggling to find solutions to the problem. Some clients have reported claims that were made in their names when they had not even been ill, with the medical aid companies seemingly reluctant to pursue the cases further because of the complications involved.

Botswana Medical Aid Fund (BOMAID) has a system where clients are notified through text messages the payments made to service providers, and there has since emerged a trend where these clients knew nothing about the reported visits to the specified doctors or medical facilities. “In my case, I received a text message that said payment had been made to a particular medical facility where I had reportedly gone for some surgery last month. I was surprised to see the text message because I never had any surgery and I had never set foot at that medical facility.

I reported the matter to BOMAID and I have since been told an investigation is being carried out. I have received no update since,” one aggrieved client told The Midweek Sun. In another incident also handled by BOMAID, a client says after the medical aid service provider had eventually traced a dubious claim, he was told he had visited a doctor he does not even know. “I was told there are receipts to prove I had been to that doctor, but it was the first time I heard his name. In the meantime BOMAID had already paid for my reported illness, whose notification I received by SMS.

The person I spoke to at BOMAID admitted that such cases were difficult to detect, but promised they would follow up the matter,” the aggrieved client related. Speaking to this publication, BOMAID Sales and Marketing Manager, Beaulah Mapitse said they are aware of such acts and they always ensure that they assist their members according to their benefits. “Despite the loss we incur from fraud we always want to protect our members and assist them according to their benefits,” she said. She acknowledged there have been such cases of fraud from some medical practitioners but the fund will not punish the member.

“We always protect our clients; in cases whereby the client complains that he has been cheated through his policy, we investigate the problem and assist him. The process is long because we do not have the intelligence systems to detect the problem. “If it happens we refer the issue to our governing body, the Botswana Health Professionals Council,” she said. Mapitse explained that they have over time tackled specific cases in line with the peculiarity of each case. “The way to tackle the situation is to have measures in place to proactively detect and address cases of fraud. This requires a multi-disciplinary skill set (clinical, financial, audit, actuarial etc.) as well as robust and integrated information management systems,” she said.