The relationship between the level of knowledge and opportunities of fraudulent activities amongst members of the medical scheme industry.

Abstract

The nature of a medical scheme is a complex one; this is due to the benefit structure, language and terminology used by medical scheme companies. Additionally, in a multidisciplinary healthcare sector, various role players possess different expert knowledge. The challenge that has been identified, is that patients may be susceptible to making uninformed decisions, due to not being equipped with information that is simple to understand by the medical scheme and relevant patient-specific information provided by the various healthcare professionals. Disclosure of information that is straightforward by the medical scheme and the right of the patient to receive information that relates to disease management will enable the patient to be proactive about the quality of information that they must gain from the healthcare professional. This study shall investigate the knowledge, perceptions and understanding about medical schemes functionality and the opportunities of fraudulent activities that can be within the medical scheme industry. The research method applied in this study was a quantitative approach, which involved the recruitment of 100 participants. A descriptive survey was distributed to the eligible participants. Thereafter, the data was collected and analyzed using an SPSS data analysis system, which indicated that participants had a better understanding and level of knowledge for factors such as Co-payments, Prescribed Minimum Benefits, Designated Service providers and fraudulent activities in the medical scheme Industry. Unlike, responses provided for benefit options, scheme rules and legalities, participants showed a lack of understanding. The connection between how much information the participants knew about medical schemes and the occurrence of fraudulent activities was not achieved, as the responses were either good for one section and bad for the other. Going forward, it can be recommended that medical scheme companies provide their members with easy to understand information about the key-features of the scheme and most importantly that healthcare professional’s open-up to sharing information with their patients, to enable them to make good decision.