By Michael Gwarisa
Zimbabwe is witnessing a sharp rise in healthcare fraud, particularly within the private healthcare sector, with an estimated 1,577 cases reported in 2024, the Association of Healthcare Funders of Zimbabwe (AHFoZ) has revealed. As a result, 13 service providers and medical doctors have been blacklisted, rendering them ineligible to offer services under medical aid schemes.
AHFoZ Board Chairman Stanford Sisya, told HealthTimes that service providers are employing sophisticated methods to bypass systems and inflate claims for services that would otherwise cost less.
“Yes, there are institutions and practitioners that have been suspended, with their AHFoZ numbers withdrawn for engaging in healthcare fraud,” Sisya said.
One of the most common fraudulent practices in the private healthcare sector is up-coding, where a service provider enters a billing code for a more expensive procedure than what was actually performed. This practice allows healthcare professionals to claim higher reimbursements from medical aid societies.
“It’s called up-coding. Service providers can be quite innovative around it because everyone wants money. A common example is when a gynecologist enters a code for services that should only be provided by a physician in order to claim a higher fee,” Sisya explained.
Another form of fraud involves ghost patients, where service providers submit claims for services never rendered. In some cases, doctors charge for procedures that require specialized equipment they do not possess or charge for consultations that never happened.
To combat this growing problem, AHFoZ has set up a risk management committee to monitor and flag suspicious trends.
“We have a committee that operates under AHFoZ where members share information on fraudulent trends they have identified. If a particular provider is flagged multiple times, an investigation is launched,” Sisya said.
He added that digitalized systems are being encouraged to help detect fraud in real time.
“We are urging our members to invest in digital fraud detection systems. These systems can automatically reject suspicious claims and provide reasons for rejection. This ensures that fraudulent activities are curtailed before payments are processed,” he noted.
While fraudulent service providers are penalized, Sisya emphasized that the industry prioritizes rehabilitation over punishment.
“The way we are running the industry right now is that we don’t immediately abolish a provider from medical aid services. Our first priority is to rehabilitate them and, where possible, recover the funds they have inappropriately claimed,” he said.
“If a provider’s AHFoZ number is withdrawn, they will no longer be able to process medical aid claims, which is a last resort.”
AHFoZ also conducts both scheduled and ad hoc inspections of healthcare providers.
“We inspect healthcare facilities to ensure they meet our standards. Sometimes we find shocking conditions. For instance, a provider may claim to operate a medical facility, but upon inspection, we find a backyard setup with people cooking food next to medical equipment,” Sisya revealed.
AHFoZ’s Chief Executive Officer, Shylet Sanyanga, added that medical aid members also contribute to healthcare fraud through abuse and misuse of benefits.
“There is a distinction between fraud, abuse, misuse, and error. Fraud is a crime that we can report to the police. Abuse and misuse, however, occur when individuals exploit the system for their own benefit,” she explained.
“For example, a medical aid member might claim a prescription but instead use the funds to purchase non-medical items such as make-up. We have trained assessors who analyze data to detect inconsistencies in claims,” Sanyanga said.
She further highlighted cases where patients collude with healthcare providers to defraud medical aid schemes.
“Sometimes, members visit a doctor for a minor ailment but receive tests or prescriptions unrelated to their condition. For example, a man might visit a doctor complaining of a sore thumb but later be found to have claimed for a pregnancy scan. These inconsistencies raise red flags in our system.”
Other prevalent forms of healthcare fraud include:
- Phantom billing: Charging for services or procedures that were never performed.
- Unbundling: Billing separately for procedures that should be part of a single package, thereby increasing claim amounts.
- Kickbacks: Healthcare providers referring patients to specific pharmacies, labs, or specialists in exchange for financial incentives.
AHFoZ has called for increased vigilance and stricter regulations to curb the rising cases of fraud, emphasizing that medical aid schemes must prioritize system upgrades to detect and prevent fraudulent activities.
