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First Mutual Health

Monthly Newsletter
October : 2014

Contents
Page

Medical Aid Fraud ... 2


Why Generic Drugs?............................... 4
First Mutual Clinic .... 5

FIRST MUTUAL HEALTH, First Floor, First Mutual Park,


100 Borrowdale Road, Borrowdale, Harare, Zimbabwe | P O Box 1083, Harare.
Tel: +263 (4) 250420-4, 798517-23, 886018-36 | Fax: +263 (4) 886068, 886069
E-mail: info@fmlmedical.co.zw | Website: www.fmlmedical.co.zw

News Bulletin

Title

MEDICAL AID FRAUD


healthcare fraud as a deception or misrepresentation
that a person or entity makes, knowing that the

Fraud committed by members:

Membership substitution - members using their


medical aid card for other people to use who
are not registered dependants.

misrepresentation or a deliberate omission which

Non-disclosure of previous medical conditions.

results in benefits being granted, which would

Submitting false or altered invoices.

Colluding with a service provider to submit false


claims.

Dual membership - belonging to two medical


aids simultaneously.

misrepresentation could result in some unauthorised


benefit to the individual or entity or another party. The
most common fraud involves a false statement, a

otherwise be denied.

What is the impact of fraud on members


of a medical aid?
Medical aid fraud costs the Zimbabwe medical aid
industry millions of dollars per year. While figures for
Zimbabwe are not available, statistics from the South
African Medical Association indicates that in 2010,

Fraud committed by service providers:

Code manipulation - charging for a more


expensive procedure by billing for tariff codes
with a higher monetary value, or charging for
codes in respect of services not provided.

Submitting accounts for services not rendered


sometimes in return for a cash payment to the
member.

Merchandise substitution - eg providing a


member with a nebuliser and charging for an
oxygen tank.

Generic instead of branded - provider dispenses


generic medication and charges for the original
medication.

Providing services which are unnecessary.

Claiming for non-covered benefits under codes


that are covered.

R400 of a member's average contribution went to


covering losses and combatting fraud as a result of
fraudulent activities.
Fraud is committed by various parties including service
providers, members, brokers and other parties with the
main perpetrators being service providers and
members. Money spent on fraud means that there is
less money to spend on healthcare expenses.
Example:Peter visits his doctor who gives him cash
and sends a claim through to the medical aid for a
consultation and medication. This happens regularly
and Peter's benefits are depleted by June. Peter's four
year old daughter suffers from eczema and needs to
go to the doctor for treatment, but there are no
benefits. It is three weeks before payday and Peter
does not have cash to pay for the consultation. Peter
forgets that he has submitted fraudulent claims which
have depleted his benefits.

A member of First Mutual Holdings Limited

The Association of Certified Fraud Examiners defines

What is the impact of fraud on members


of a medical aid?

First Mutual Health News Bulletin

What is fraud?

MEDICAL AID FRAUD contd


Direct financial losses to the members of the
medical aid

Investigation costs

Management time

Legal costs

Reputational damage

Ultimately all leads to increased


contributions for the members

Real examples of fraud committed in


Zimbabwe:

A dependant's mother, who is not a member of


the medical aid, is claiming for services under

The following will happen when a member is found to


be guilty of committing fraud:

Scheme membership will be terminated.

All fraudulent claims will be reversed and the


member will be liable to pay them.

The member will be reported to the


participating employer group where the
member's contribution is subsidised by an
employer.

A criminal case will be opened.

The following will happen when a service provider is


found to be guilty of committing fraud:

her daughter's name (who is a member of the

All fraudulent claims will be reversed.

medical aid).

Direct payment to the provider will be stopped.

A member with two wives used the first wifes

The provider will be reported to the relevant


regulatory body.

A criminal case will be opened.

medical aid card to treat the second wife who


was not a member. The sick wife died in
hospital and the fraudulent act was discovered.

A pharmacy held back a claim from December

How can you prevent fraud?

2012 as the member's benefits were depleted

Analyse your claims statements carefully. Check


that you have received the services claimed for
by the service provider.

Keep your medical aid number and medical aid


card in a safe place.

Refrain from accepting money in exchange for a


claim from your medical aid.

Report suspicious behaviour.

and re-submitted the claim in 2013 under a


2013 service date once the member's benefits
were renewed.

A member obtains scripts from several GPs and


uses these to purchase habit forming
medication for resale on the black market.

A dentist submits a claim for dental flossing on


a two year old child.

A member of First Mutual Holdings Limited

What are the consequences for members


and providers who commit fraud?

First Mutual Health News Bulletin

The direct consequences of healthcare


fraud are:

Why Generic Drugs?


What are generic drugs?
A generic drug is a chemically equivalent, lower-cost version of a brand-name drug, costing 30-80% less! A brand-name drug and
its generic version must have the same active ingredient, dosage, safety, strength, usage directions, quality, performance and
intended use.

Are generic drugs as safe as brand-name drugs?


Yes. Generic and brand-name drugs must meet the exact same standards for effectiveness, safety and quality.

Do generics take longer to work?


No. Generic drugs work in your body in the same way and in the same amount of time as brand-name drugs

Are brand-name drugs manufactured in better facilities than generic drugs?


No. Both brand-name and generic drug facilities must meet the same standards. The MCAZ tests and approves all drugs to ensure
standards are met. In fact, brand-name firms are linked to an estimated 50% of generic drug production. They frequently make
generic copies of their own or other brand-name drugs, then sell them with a generic name.

What is the price difference between generic and brand-name drugs?


In 2008, the average price of a brand-name drug was $137.90, while the average generic prescription cost $35.22, according to
the National Association of Chain Drug Stores in the United States. In addition to the savings on the price difference, there is also
a savings on your copayment, if any, for using a generic drug over a brand-name drug.

If generic drugs are just as good as brand-name drugs, why do generics cost less?
When a company develops a new drug and submits it for regulatory approval, a 20-year patent is issued, preventing other
companies from selling the drug during the life of the patent. As a drug patent nears expiration, any drug manufacturer can apply
to the regulatory authority to sell its generic version. Because these manufacturers didnt have the same development costs (such
as years of expensive research), they can sell the drug at a discount. Once generics are allowed, the competition keeps the price
down. Today, almost half of all prescriptions are filled with generics.

Why do some generic drugs look different from their brand-name versions?
All drugs have inactive ingredients such as dyes, fillers and preservatives. These ingredients often determine the size, shape and
color of the drug. Trademark laws do not allow a generic drug to look exactly like its brand-name version. A generic drug must
duplicate the active ingredient and it must be equally effective, but the color, shape, and other inactive ingredients may be
different.

How do I get generic drugs?


Talk with your doctor and pharmacist. Explain that you want the most effective drug at the best price. Ask your doctor to write
prescriptions for generic drugs whenever possible.

Whats the bottom line on generics?


You can use generics with confidence. Although they may look different from their brand-name versions, generics are safe and
effective. As always, any medication changes must be discussed with your physician and pharmacist.

First Mutual Health News Bulletin

Yes. The Medicine Control Authority of Zimbabwe requires generic drugs to have the same quality, strength, purity and stability as
their brand-name versions. Generic drugs are thoroughly tested to make sure their performance and ingredients meet the MCAZs
standards for equivalency.

A member of First Mutual Holdings Limited

Are generic drugs as strong as brand-name drugs?

(Between First Street & Angwa Street)

Harare

Telephone contact 798 493 / 798 491-6

A member of First Mutual Holdings Limited

Operating times are as follows:

8:00 am to 6:00 pm Monday to Friday.


8:00 am to 12:30 pm Saturday
The clinic is closed on Sundays and Public Holidays.

The clinic is situated at:

2nd Floor
Bryanston House
No. 9 George Silundika Avenue

First Mutual Health News Bulletin

First Mutual Clinic

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