Wandile Theophilus Mashego, an audiologist and speech therapist practising in Pretoria, has been found guilty of 259 counts of medical aid fraud and one count for contravening Section 66 of the Medical Schemes Act.
The case was brought against him by Bonitas Medical Fund after it was discovered that he had been submitting fraudulent claims on behalf of members from 2014 to 2015.
A soon to be identified ‘runner’ provided details of Bonitas Medical Fund members to Mashego, who then billed Bonitas fraudulently, for ‘services’ to these members.
Mashego pleaded guilty under Section 105A of the Criminal Procedure Act 77 of 1951 and was sentenced to five years’ imprisonment, wholly suspended for five years, on the 259 counts of fraud. The conditions include, amongst other things, paying Bonitas back R506k as from 1 August 2018 (failure to pay will result in direct imprisonment); correctional supervision for 36 months, which includes community service of 16 hours per month; and house arrest for a period of 36 months (except when going to work).
“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 no service having been rendered to them,” said Chief Operating Officer of Bonitas, Kenneth Marion.
“We are indebted to the whistle blowers and to SAPS for ensuring that he was convicted and sentenced and for other recent convictions and sentencing we have had in the recent months,” continued Marion.
It is estimated that 15% of claims in the healthcare industry contain an element of Fraud, Waste and Abuse (FWA). For a scheme of Bonitas’ size, this translates to a loss of R190 million.
“To address this, we implemented initiatives against FWA, including hospital and pharmacy claim analytics. The result was the identification of FWA of R129.8 million, with R31.2 million recovered in 2017,” said Marion. The Scheme further benefitted from R75 million in potential savings.
“Five imprisonment sentences have been handed down by the judiciary – clearly indicating a zero tolerance approach to this white collar crime,” said Marion.
According to Section 66 of the Medical Schemes Act, medical aid fraud, committed either by a member or a healthcare practitioner, is a criminal offence which carries a fine or imprisonment or both. In the instances where a healthcare provider is guilty of committing fraud, all fraudulent claims are reversed and the healthcare provider is reported to the relevant regulatory body and a criminal case opened.
A member found guilty of committing fraud will have their membership terminated. One member was terminated by Bonitas during quarter 2 of 2018 for involvement in fraudulent activities. All fraudulent claims submitted will be reversed and the member will be liable for them. A criminal case will also be opened. In addition, members who commit fraud may also have their employment jeopardised – especially in cases where their medical aid contributions are subsidised by their employer.
“The repercussions of fraud are widespread but it has a very direct impact on each and every member of the Fund. 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 transplants,” said Marion.
“We are encouraged at the increased reports by our members. Fraud directly impacts them so we all need to be more diligent in checking our billings and questioning unnecessary procedures. The contribution by members, combined with our internal fraud-tracking system and investigations by SAPS and prosecution by NPA will all work together to put a stop to FWA and help reduce spiralling healthcare costs. It’s a win-win for everyone,” concluded Marion.
Bonitas’ toll-free fraud hotline is: 0800 112 811