Stop Providers that commit fraud

Stop Providers that commit fraud


Our Objective:

Prime Cure’s objective is to curb incidences of fraud and other inappropriate behavior while building member awareness.

Prime Cure actively investigates all allegations and tip offs relating to fraud such as unethical behaviour, abuse and over servicing in terms of the utilisation of benefits. If you suspect fraud by a fellow member or healthcare provider please report it to the Prime Cure Forensic department using the contact details below. You can choose to remain anonymous or to provide your personal details.

How to check?

Please take the opportunity to scrutinise your paid claims on the member log in.

Check the following information on the claim;

  • Membership details > the details of the patient
  • Name and dependant code
  • The name of the healthcare provider that submitted the claim
  • The date when the healthcare provider rendered the service (date when consultation, treatment or investigation took place)
  • Should you be in any doubt as to the accuracy of this information contact the Prime Cure call centre on 0861 665 665 where you will be assisted by a Service Center Agent. Alternatively, please send us a fax on 0865 571 909 or email us at Forensics@primecure.co.za

Please take note of the following and remember to share this information with your dependants who are legible for benefits through your Medical Scheme.

  • Never lend your medical scheme card to anyone. Your medical scheme membership card may only be used by the individuals whose names appear on the card and who are eligible for benefits.
  • Never leave your membership card with a provider. Please keep it in your possession at all times.

Listed below are some examples of fraud committed by healthcare providers and members.

  • Billing for services not provided.
  • Cash loans. For example, healthcare providers handing out cash to members in exchange for submitting a claim to the Medical Scheme.
  • Dispensing merchandise to patients. For example, pharmacies dispensing cosmetics to members and then claiming for dispensing medication to the member from the medical scheme.
  • Altering or tampering with prescriptions by pharmacies. For example, two types of medication are prescribed, recorded on the script and dispensed. The pharmacy enters two additional types of medication on the script and adds these to the claim.
  • Provider syndicates sharing the medical scheme details of members and submitting false claims on behalf of members they have never consulted with.
  • Re-submitting claims that have been rejected previously, for example changing the claims information on rejected claims and re-submitting until they are paid.
  • Providing kickbacks. Providers receiving cash paybacks for referring patients to a specific hospital or healthcare provider.
  • Charging more than once for the same service.
  • Over servicing, for example a provider requests patients to come back for a follow up visit which is not necessary.
  • Using invalid tariff codes.
  • Inflating of claims.
  • Medical scheme cards being used fraudulently. For example the member lends his or her medical scheme membership card to family members or friends who are not registered beneficiaries of the medical scheme.
  • Collusion: working together with a provider in order to submit a fraudulent claim and sharing in the money received.
  • Abuse of benefits, visiting the General Practitioner when you are not sick but require a sick note so you can stay off work.
  • Dual membership. In other words, the member joins two medical schemes at the same time.
  • Non-disclosure of prior ailments when applying for scheme membership.
  • Never leave your membership card with a provider. Please keep it in your possession at all times.