Bestmed Medical Scheme, South Africa's fourth-largest open medical scheme, is preparing to integrate Artificial Intelligence (AI) into its systems. This initiative aims to combat the growing scourge of fraudulent claims plaguing the healthcare industry. Protecting members' funds and ensuring the scheme's long-term sustainability amidst rising operational pressures are also goals.
Bestmed CEO and Principal Officer Leo Dlamini confirmed that the scheme was leaving no stone unturned in its efforts to curb fraud, waste, and abuse. He stated that while the medical scheme industry continues to face increased challenges, Bestmed remains committed to investigating all suspicious cases. They are also exploring the use of AI integration to analyse claims data and quickly identify and manage irregularities.
The Sophisticated Nature of Healthcare Fraud
The medical aid industry is battling a surge in fraudulent activities. These activities are becoming increasingly audacious. Dlamini cited a stark example. A doctor in Polokwane submitted a claim for speech therapy for a deceased person. The person had just passed away in a hospital in Gqeberha before the family had even been notified of the death.
This type of organised fraud, alongside rising specialist and oncology costs, is a significant driver of escalating healthcare expenses for all members.
Battling Rising Costs in a Post-Pandemic World
The fight against fraud comes as the industry grapples with significant financial strain. According to Dlamini, schemes are experiencing a full return to pre-pandemic levels of elective surgeries and routine care. There is also a worrying rise in complex cancer diagnoses and other conditions requiring intensive, high-cost treatment.
As Dlamini pointed out, we are also seeing the effects of more advanced treatments and higher-priced medications. Members have increasingly complex health conditions that require specialist care. These factors aren't short-term issues. They're part of a broader, long-term trend that will continue to impact medical schemes and their members.
Despite these headwinds, Bestmed reported a 4.4% growth for the 2024 financial year. This marks its sixth consecutive year of growth, with total assets increasing from R4.9 billion to R5.4 billion.