Dodgy speech therapist nailed after patients speak up
Pretoria audiologist gets house arrest, must repay R506,000 for 259 counts of medical aid fraud
A sharp spike in claims and members questioning suspicious claims submitted on their accounts, have nailed a Pretoria speech therapist and audiologist.
Wandile Mashego was found guilty on 259 counts of medical aid fraud when he appeared in the Roodepoort Magistrate’s Court this month, and received a five-year suspended sentence.
Bonitas Medical Scheme detected the fraud through specialised software, and reported him to the police.
Chief operating officer Kenneth Marion said: “We identified a sharp spike in his claims and some members contacted the scheme complaining about claims submitted on their accounts without their knowledge and with no service having been rendered to them.”
Mashego was aided in his elaborate scheme by someone who was able to access Bonitas medical members’ details, which he sold to the therapist.
The medical aid warned all members to make sure they keep track of all claims and report anything that does not add up.Mashego has been ordered by the court to repay R506,000 to Bonitas, starting this month, or face imprisonment.
He will be under house arrest for the next three years, but is allowed to continue working. However, the judgment stipulates he is only allowed to work for somebody else, and not run a private practice.
The house arrest conditions also include not drinking alcohol, not going to bars or nightclubs, and not owning a firearm.
Mashego is not permitted to leave Pretoria until the end of 2021.
Marion said the medical scheme is getting serious about cracking down on healthcare fraud, which takes money that is meant to be used for members’ medical treatment.
The money lost through suspected fraud in 2017 could have paid for a GP visit for 57,000 members.
Bonitas and other medical aids use forensic software that detects strange billing patterns.Discovery Health claimed back R1bn lost to fraud over three years, but said more was saved because as doctors get caught, others stop committing similar fraud for fear of getting caught.
According to Bonitas, it is estimated that 15% of claims in the healthcare industry contain an element of fraud, waste and abuse. For a scheme of Bonitas’ size, this translates to a loss of R190m.
“The repercussions of fraud are widespread but it has a very direct impact on each and every member of the fund,” said Marion.
“Medical schemes are owned by their members and when money is defrauded from the scheme it can contribute towards increased premiums. In fact, the money we recovered last year could have been used to pay for around 57,000 more GP consultations or 18 lung or liver transports.”
Discovery Health has been taken to court by doctors who say they should not have been accused of fraud and pay back money. The case is before the courts.
One of the complainants gave his doctor’s practice number to a fake doctor who treated patients and then claimed on his behalf. The doctor is still practising.
Another GP accused of fraud claimed for offering ultrasounds to patients, but could provide no proof he owned the ultrasound equipment he claimed to have used.
In another case, four healthy undercover investigators visited a doctor who gave them fake sick notes so they could miss work.Despite this evidence they are challenging Discovery Health and accuse the medical aid administrator of spying on them with undercover patients who used spy cameras.
Bonitas Medical Scheme said it has noticed a spike in unqualified people using doctors or therapists’ medical practice numbers and claiming on their behalf for “treating” patients.
At other times, pharmacists sell nappies, cosmetics or other goods to the member and claim from the medical aid for the sale of medicines. This is very hard to detect, said Marion.
Other popular types of health worker fraud:
The patient and doctor work together to defraud the scheme for services not rendered, and split the money claimed;
Doctors, social workers and physiotherapists, among others, charge for more than 24 hours a day;
Psychologists charge for a 45-minute appointment when the counselling session was 30 minutes;
Dispensing doctors and pharmacists claim for two to six months of medicine when they dispensed only one month to the patient, who may not check the medical aid claim and won’t realise they paid for more than they used;
Doctors claim for procedures that have not been done, such as a urine test, and the cost of equipment used, such as needles or gloves.