Special Assignment

Medical Aid Scam

According to healthcare funders, medical aid fraud is one of the leading crimes in South Africa. It is estimated at between nine and 19 billion rand a year, money which could have been better spent on providing quality health care for all.

Special Assignment exposes a series of bogus surgeries operated by a syndicate of fake doctors that have fleeced medical aids of millions of rands. The head of the syndicate was convicted for operating an illegal abortion clinic at Lister Medical Centre in Johannesburg in 2015. He and his then partner, an Ivorian national, pleaded guilty to the crime, paid a fine and received a three-year suspended sentence.

Despite his conviction, this doctor continues to operate a series of dodgy surgeries run by foreign nationals in Heidelberg, Duduza and Boksburg. Sergeant Cebisa Maseko of the SAPS in Boksburg says that police are investigating links that the syndicate is recruiting fake doctors from the Congo to come and work in South Africa.

Armed with a medical aid probe card which medical aid fraud investigators use to trace fraudulent claims, and a hidden camera, our investigator goes undercover to visit several bogus surgeries in Gauteng. He witnesses perpetrators fraudulently consulting, diagnosing and submitting claims to medical aids.

At one such surgery, our undercover investigator consulted a ‘doctor.’ A medical fraud investigator tracked the claim for his consultation through the use of a probe card. Initially, a seemingly insignificant claim of R5.50 was submitted. A month later, the full amount, over R500, was submitted. The forensic investigator explains this as the modus operandi of the syndicate. Small claim amounts are used to test the system. Once paid, larger amounts are put through.

Despite arrests at ‘practices’ in Boksburg and Diepsloot the syndicate is still up and running.

Medical Aid Scam highlights the fact that much more needs to be done to protect unsuspecting patients and to close loopholes through which fake medical practitioners defraud them and their medical aids.

Watch Medical Aid Scam, produced by Frank Ferro, on Special Assignment. Wednesdays at 21h30 on SABC3.