Bestmed Medical Scheme, SA’s fourth-largest open medical scheme, is exploring how to deploy AI to fight the scourge of fraudulent claims besieging the industry.
Bestmed CEO and principal officer Leo Dlamini said the scheme was leaving no stone unturned to curb fraud in the system.
“While the medical scheme industry continues to confront increased fraud, waste and abuse challenges including false claims and code farming, Bestmed actively continues to investigate all suspicious cases and is exploring AI integration to analyse claims data rapidly and manage irregularities,” Dlamini said.
“We have a fiduciary duty to our members to manage their contributions with integrity and transparency, and to ensure those funds are used responsibly to pay for genuine healthcare services.”
AI has increasingly become an indispensable tool at the hands of organisations to both improve efficiencies and curtail fraudulent activities.
In terms of fraud prevention, technology group Naspers said AI was responsible for 60% of all payment decisions, with 97% approval rate.
The SA Revenue Service is also on the hunt for cutting-edge AI technology to improve its efficiency, which it has said is at the heart of its bid to recoup about R800bn in uncollected taxes.
The tax agency in its request for information said it was looking to procure AI capabilities that would enable the utility to “replicate and automate complex, human-logic decision-making processes across its operations”.
The medical scheme industry has seen a surge in specialist and oncology costs, coupled with the high incidence of fraud as being among the cost drivers.
An example of the type of fraud the industry has to contend with is of somebody who died at a hospital in Gqeberha, and before the family is even informed a doctor in Polokwane sends a claim of the deceased person for speech therapy.
Dlamini said the industry continues to face substantial strain, not only from an industry growth perspective, “but also from a sharp rise in healthcare costs and a surge in more complex, expensive medical cases”.
The scheme reported a 4.4% growth in the 2024 financial year the sixth consecutive year it registered growth.
The company’s total assets increased to R5.4bn in the year under review from R4.9bn. Dlamini said the scheme was seeing a full return to elective surgeries, routine check-ups and specialist care post-pandemic — alongside a rise in complex cases and cancer diagnoses that demand intensive and high-cost treatment.
“We’re also seeing the impact of more sophisticated treatments, higher-cost medications and members presenting with increasingly complicated health conditions that need specialised care.
“These factors are not short-term challenges; they’re part of a longer-term shift that will continue to affect medical schemes and their members,” he said.
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