Bianca Visagie - Healthcare Specialist

16/12/2025

16/12/2025

Did you know?!

If you are a Bonitas Medical Aid member, you can sign up to the Bonita's maternity programme, you will receive a FREE Baby Bag filled with essential goodies!

We give all pregnancy members a beautiful baby bag to congratulate you on the arrival of your bundle of joy.

The baby bag is packed with goodies for you and your newborn.
This may include baby wipes, or toy, bath products, toiletries and other items*.

To register for your baby bag, you must be at least 24 weeks pregnant and have obtained pre-authorisation for your delivery.
To register for the benefits of the programme, please call
087 056 9888

*Contents depended on the availability

16/12/2025

This Day, remember to reflect on the love you have in your life from those around you.

Remember to share in the beauty that is life and do something Personally Yours for someone else.

Happy Reconciliation Day from Bestmed!💙

16/12/2025

Want theBESTfor you and your family?
Bestmed offers access to an extensive service provider network nationwide, including GPs, specialists, dentists, hospitals, etc.

Bestmed offers an extensive range of maternity benefits across all options.

Female contraceptives are covered on ALL options, with a benefit limit per female beneficiary per family.

Bestmed does two claim payment runs every week to help with your cash flow.

Bestmed members pay child dependant rates for children up to 24 years old.

13/12/2025

Your best life starts with better health​.
Your journey to wellness starts here.​
Simple actions. Real rewards.

13/12/2025

You can laugh off a bold spot, but a medical bill shortfall? Protect your wallet and let Sirago cover the gaps your medical aid does not cover.

12/12/2025

Make sure your December 2026 stays Decembering by planning ahead.

From 2026, a separate additional intrauterine device (IUD) benefit has been added under the female contraceptives benefit across ALL options.

03/12/2025

orangeblock

FaNews
Menu
Search
search

Fraud and abuse pose a silent threat to healthcare sustainability
28 November 2025 | Healthcare | General | Kevin Aron, Principal Officer at Medshield Medical Scheme
Fraudulent claims and provider abuse may not dominate headlines in the same way as medicine shortages or hospital waiting lists, yet their impact on healthcare sustainability is profound. Every falsified claim, inflated bill, or unethical practice chips away at the collective resources members entrust to their schemes.

Medical schemes define fraud as deliberate misrepresentation – whether it's billing for services never rendered, upcoding procedures, or collusion between providers and members. Abuse, while sometimes less clear-cut, refers to practices that take unfair advantage of scheme rules, driving costs higher without delivering genuine value to patients.

In South Africa, where healthcare costs already strain household budgets and system resources, these practices are particularly damaging. Fraud not only harms the finances of medical schemes but also undermines affordability, reduces the scope for benefit enhancements, and erodes trust between members and their schemes.

Understanding the impact

Globally, it is estimated that up to 15% of healthcare claims may be tainted by fraud, waste, or abuse. In South Africa, this translates into billions of rand lost each year, as evidenced by the 2023 estimate that the healthcare sector had lost R30 billion to fraud, waste, and abuse. The consequences are felt directly by members, who face rising contributions, reduced benefits, or both.

Encouragingly, Medshield's proactive approach is proving effective. In 2024, forensic reviews and claim interventions delivered nearly R16 million in measurable savings, with a return on investment of over 250%. It demonstrates that careful, targeted investment in fraud prevention not only pays for itself but multiplies the value of every rand spent.

Fraud in healthcare is often sophisticated, but specific patterns recur:

Phantom billing – charging for services never provided.
Upcoding – claiming for more complex or costly services than those delivered.
Service inflation – conducting and billing for unnecessary tests or procedures.
Identity fraud – impersonating members to submit illegitimate claims.
In 2024, South Africa experienced a 337% increase in impersonation fraud, with syndicates targeting both healthcare and banking sectors. Cases investigated included providers misrepresenting patient records or even hiring impostors to treat patients under another practitioner's name. These examples illustrate the inventive and damaging tactics employed by fraudsters.

Medshield's multi-layered response

Recent industry case studies highlight how fraud can manifest in diverse ways. In one instance, phantom claims were submitted for services that never occurred but were identified and stopped before they could escalate into significant losses. In another case, hospital billing practices were reviewed when catheterisation laboratory procedures were incorrectly paired with major theatre charges, leading to corrective action and stronger controls. These examples illustrate how vigilant oversight not only prevents financial leakage but also safeguards the integrity of healthcare systems.

At Medshield, fraud prevention is not simply an administrative task. It is a strategic imperative grounded in protecting member value. Our approach spans several layers:

Technology-enabled detection – Artificial intelligence and predictive analytics scan claims in real time for irregular patterns or anomalies.
Targeted audits – Both random and focused audits are performed, particularly in high-risk areas such as specialised procedures or hospital billing.
Provider accountability – Collaborations with professional bodies, have led to constructive resolutions where billing irregularities were identified, creating a positive ripple effect across entire networks.
Frontline vigilance – Claims assessors and customer-facing teams receive specialist training to identify potential fraud before funds are disbursed.
Collaboration – Medshield participates in industry-wide forums and public–private partnerships that enable data-sharing and collective action. Our forensic partners were even recognised globally in 2024 by the Association of Certified Fraud Examiners (ACFE), reflecting the calibre of expertise applied to protecting our members.
Fraud prevention is not without its challenges. Fraudsters continually evolve their tactics, and emerging technologies such as artificial intelligence now pose risks in the form of synthetic identities and deepfakes. Meanwhile, schemes must strike a balance between robust oversight and a smooth, member-friendly claims process.

Yet the opportunities are equally compelling. By expanding collaborative initiatives, strengthening data-sharing platforms, and adopting more advanced analytics, medical schemes can set new standards for fraud prevention.

A shared responsibility

Fraud prevention is most effective when everyone is part of the solution. Members are encouraged to review their claims, understand what services they should expect, and use anonymous reporting channels if they spot suspicious behaviour. On the provider side, most practitioners act with integrity, but isolated cases of abuse can harm the entire system. By combining audits with constructive engagement, Medshield promotes accountability without casting suspicion on the profession as a whole. The goal is not only to prevent abuse but also to encourage ethical practices that benefit all stakeholders.

Underlying all of these measures is Medshield's zero-tolerance stance on fraud, waste, abuse, and corruption. This commitment is reinforced by training, codes of conduct, and whistleblower hotlines that empower employees, providers, and members to report suspicious behaviour safely and anonymously. Medshield also demonstrated its industry leadership by signing the Fraud, Waste & Abuse Industry Charter in 2019, pledging – alongside regulators and sector stakeholders – to eliminate wasteful practices, improve transparency, and support a more sustainable funding model for healthcare.

Ultimately, fighting fraud is about more than money; it is about fairness. Every fraudulent claim undermines the solidarity principle that defines medical schemes: members pool resources so that those in need can access care. At Medshield, our responsibility is to safeguard this principle.

By investing in robust detection systems, building partnerships, and fostering awareness among members and providers, we ensure that the Scheme remains sustainable, affordable, and trusted. Fraud may be complex, but with vigilance and collective commitment, it can be contained. Protecting our healthcare system from abuse today ensures that tomorrow's members inherit a stronger, more resilient scheme.

02/12/2025

Discovery Health Medical Scheme shares update on new Smart Saver Plan series

01 December 2025 | Healthcare | Medical Schemes | Discovery
Discovery Health Medical Scheme (DHMS) has announced more details about its new Smart Saver Plan series, designed to meet the unique healthcare needs of young families.

As announced alongside DHMS’s contribution increases for next year, the new Classic Smart Saver and Essential Smart Saver plan options will be available from 1 January 2026.

Dr Ron Whelan, CEO of Discovery Health, administrator of DHMS explains: “For many young families, the challenge of balancing rising household costs with the need for reliable health cover is very real. The Smart Saver series addresses this challenge by offering affordable contributions, unlimited hospital cover, guaranteed benefits for essential healthcare services, and flexible benefits that adapt to each family’s unique needs.”

A new model of value - affordability, guaranteed care, and flexibility
In-depth market research and analysis by Discovery Health demonstrate that many of the healthcare needs of young families are universal – including GP visits and medicines to managing children’s injuries. At the same time, no two families are the same and many medical needs are unique. This points to a design that should offer guaranteed benefits for the universal needs, and flexible benefits for the unique needs.

As a result, the Smart Saver plan series is designed around four key pillars:

• Affordability – Designed for young families, with contributions starting from only R2,750 for a principal member, R2,350 for an adult dependant, and R895 per child on the Essential Smart Saver plan. For a family of four, pricing starts from R6,890 per month.
• Hospital cover – Unlimited benefits for hospital admissions in the Smart Hospital Network protect families against large, unexpected costs and ensure they can access quality care when they need it most.
• Guaranteed risk-funded benefits for essential day-to-day healthcare – Unlimited Smart Network GP visits, annual dental and optometry check-ups, acute and over-the-counter medicine, contraceptives, and sports and kid’s injury benefits.
• Flexibility to fund unique healthcare needs – The combination of a Medical Savings Account and the Personal Health Fund provide funding for unique day-to-day healthcare.

Data-driven benefit design defines both plan options
Market analysis shows that 84% of families visit general practitioners annually, and over 90% rely on over-the-counter medicine – making these the most commonly used healthcare services across households.

Both Classic Smart Saver and Essential Smart Saver include day-to-day cover for unlimited Smart Network GP visits, annual dental and optometry check-ups, acute and over-the-counter medicine and contraceptives. The plans also cover sports injuries, kids’ injuries, maternity, chronic illnesses, oncology and mental healthcare.
Although members of young families are statistically less likely to be hospitalised, the average admission cost remains around R70,000 per event for all members, making comprehensive hospital cover essential.

Consequently, both Smart Saver options include an unlimited number of hospital visits within the Smart Hospital Network, and full cover for network specialists. Classic Smart Saver covers up to 200% of the Discovery Health Rate for non-network specialists, and Essential Smart Saver up to 100%.

“This plan series reflects Discovery Health Medical Scheme’s commitment to understanding the healthcare risks and affordability needs of members,” explains Dr Whelan.

Integrating two powerful benefits for additional day-to-day healthcare
Smart Saver integrates two complementary benefits to supplement the guaranteed risk benefits: a Medical Savings Account and Personal Health Fund, giving families flexibility in how they manage their day-to-day healthcare needs.

Through Personal Health Pathways – Discovery Health’s AI-powered platform that guides members through personalised health actions on the Discovery Health app – members can earn up to R500 per health action completed into their Personal Health Fund, which can then be used for their day-to-day medical expenses.

“The integration of Personal Health Pathways and the Personal Health Fund means members can earn valuable healthcare benefits for engaging in personalised actions that help them sustain better health. In this way we are creating a virtuous cycle that rewards members for prioritising their health and realising additional Scheme benefits for their unique healthcare needs – a clear example of shared value in healthcare,” adds Dr Whelan.

For a family of four on Classic Smart Saver, families can earn up to R20,000 per year (up to a total of R10,000 for completing recommended health actions and an additional R10,000 for completing Health Challenges) in their Personal Health Fund. On Essential Smart Saver, families can earn up to R12,000 per year (up to R6,000 for completing recommended health actions and an additional R6,000 for completing Health Challenges) in their Personal Health Fund.

Additionally, a family of four on a Classic Smart Saver has access to R7,560 in a Medical Savings Account and R5,808 on Essential Smart Saver.

Young families show high engagement levels in Personal Health Pathways
From January to mid-November 2025:

• Over 450,000 Discovery Health Medical Scheme members had activated their?Personal Health Pathway.
• They completed more than?2.7 million weekly exercise actions?and?470,000 health actions. These included?over 72,000 mental-wellbeing assessments, 27,000 health checks, 30,000 dental checks, 8,500 mammograms, 7,500 prostate screenings and 4,700 bowel-cancer screenings.
• At the same time, members earned?more than R37 million in rewards?and accumulated over?R260 million?in their?Personal Health Funds (which can be used to cover day-to-day healthcare expenses - a tangible example of healthy choices translating into real-world value for Scheme members).

Dr Whelan adds, “We are delighted with the strong uptake and engagement in Personal Health Pathways. Our data shows that young families, in particular, value the digital experience and rewards the programme offers. Activation and completion rates are 24% and 18% higher, respectively, for young families (DHMS data, 2025), underscoring how actively they are using our digital tools to build healthier lifestyles.”

Building on proven success: Active Smart becomes the fastest-growing new plan in the Scheme’s history
The Smart Saver series builds on the remarkable success of Active Smart, which was introduced in January 2025 to meet the needs of young professionals. In less than a year, Active Smart has grown to over 22,000 lives, becoming the fastest-growing new plan in the Scheme’s history. More than 80% of new members are under 40 years, a demographic profile that has driven efficient healthcare utilisation and long-term sustainability – enabling a 0% contribution increase for members on the Active Smart medical aid plan in 2026 (maintaining 2025 rates of R1,350 per month). This positions DHMS as a leading provider of smart, affordable healthcare solutions for young professionals.

“Smart Saver has been created from the same principles that made Active Smart so successful – affordability, relevance and innovation,” says Dr Whelan. “Together, the Active Smart plan and new Smart Saver plan series reflect DHMS’s ongoing commitment to accessible, high-quality healthcare at every stage of life.”

Long-term sustainability and member value
Dr Whelan concludes, “We are committed to ensuring that every new DHMS plan balances immediate affordability with long-term sustainability. Smart Saver’s design achieves both – using data-driven insights and smart benefit structures to give families the access to care that will enable them to thrive.”

(Please note that benefits are subject to Scheme Rules, including plan specific benefit limits, co-payments and plan exclusions.)