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 entitled.

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 consider suspicious.

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 account.

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 Prime Cure.