Stop Medical Aid Card Fraud

Stop Medical Aid Card Fraud


Your rights and obligations as a provider:

We have all heard the words "beware of membership substitution" but just what does this mean?
It refers to the unlawful or fraudulent use of a Medical Scheme Card in order to obtain benefits to which the user is not entitled.

What are the motives for doing this?

It could be anything from greed to economic need, a sense of entitlement or pressure to assist a family member or neighbour in need, but it is still fraud and it affects the scheme’s ability to pay claims. Another common reason is the mistaken notion that "everyone else is doing it!

For hospital admission, consultations or benefit utilisation please follow these guidelines to eliminate any possibility of fraud. Remember you are well in your rights to check and question patients.

  • Always ensure that the member produces a valid medical scheme card and NOT a photocopy,
  • An original identity document and NOT a photocopy is needed,
  • During a first consultation a registration form should be completed in full and signed by the member,
  • In the case of a minor the form has to be completed in full and signed by an adult accompanying the minor,
  • Copies must be kept by the provider in a member file for reference purposes,
  • Should the practice of the provider issue an account before the member leaves the provider's premises, the member/patient is required to sign the account.

As a provider you have a legal and ethical obligation to report fraud and abuse and to ensure that the benefits authorised by Prime Cure are used for the benefit of its "legitimate" members. If you suspect a member is or may be committing a fraudulent act, please contact the following; Fax us on 0865 571 909 or email us at Forensics@primecure.co.za