Most of us have heard of “membership substitution”, but just what does
it mean and is it illegal?
Membership substitution refers to the unlawful and fraudulent use of a
medical scheme card in order to obtain benefits to which the user is not
What are the motives for doing this?
Individuals have a range of motives for defrauding their medical scheme.
These may range from greed to economic need, a sense of entitlement and/or
pressure to assist a family member or neighbour in need. Another common
rationalisation given for fraud is that “others do it so why can’t I?”
For hospital admission, consultations or any benefit utilisation please
follow these guidelines in order to prevent possible fraud. Remember as a
provider you have the right to check and question any transactions that you may
Always ensure that the member produces a valid medical scheme card and
NOT a photocopy.
An original identity document is necessary. Do NOT accept a photocopy
under any circumstances.
During a first consultation a registration form should be completed in
full and signed by the member.
In the case of a minor the form has to be completed in full and signed
by an adult accompanying the minor.
Copies of forms, documents and records must be kept by the provider in a
patient file for reference purposes.
Should the provider’s practice management system issue an account before the
member leaves the provider’s premises, the member or patient must sign the
As a provider you have a legal and ethical obligation to report fraud
and abuse and to ensure that the benefits authorised by Prime Cure are used
correctly and for the benefit of legitimate members. If you suspect a member is
or may be committing a fraudulent act please contact the Forensic department at