Fraud Awareness: Protecting Your Benefits, Protecting Your Scheme

At Remedi, our commitment is to safeguard the health and financial wellbeing of every member. A crucial part of that responsibility is maintaining the integrity and sustainability of the Scheme.

One of the greatest threats to the long term stability of any medical scheme is fraud, waste and abuse of benefits, a growing challenge across the healthcare industry.

Fraud not only violates the trust on which our Scheme is built; it directly impacts the affordability of contributions and the availability of benefits for all members. Remedi has a strict zero tolerance approach towards fraud. Each member can help protect the Scheme by using benefits responsibly and reporting suspicious activity.

What Is Considered Fraud?

Healthcare fraud happens when a member, healthcare provider, or third party intentionally submits false or misleading information in order to gain benefits or receive payments they are not entitled to. While some actions may seem harmless or "just helping someone out," they constitute fraud under the Medical Schemes Act and have serious consequences.

Common member related fraud includes:

Submitting false claims - for example, claiming for services or items that were never received.
Using someone else's membership card - allowing a friend or family member to use your medical aid details is illegal, even if no money changes hands.
Sharing your chronic medicine with others - benefits are strictly allocated for your treatment only.
Colluding with a provider - for example, agreeing to claim for a more expensive service than what was performed.
Not paying providers - sometimes claims are directly paid to members and the member then has the responsibility to pay the provider. Keeping the money without paying the provider is a fraudulent act.
ATM fraud - colluding with the provider to claim for services and then share the money between the provider and the member.

Common provider related fraud includes:

Billing for services not rendered - charging for consultations, tests, or procedures that never occurred.
Upcoding - submitting claims for higher priced services than what was actually delivered.
Performing unnecessary procedures - conducting tests or treatments solely for the purpose of claiming more.
Splitting or inflating accounts - manipulating invoices to access benefits multiple times.

If you ever feel pressured by a provider to behave dishonestly, or something doesn't feel right, it is important to speak up.

Why Remedi Has a Zero Tolerance Approach

Fraud is not a victimless act. Every fraudulent claim, no matter how small, removes funds from the Scheme's reserves. These reserves exist to protect you and your family when you need care most.

Because medical schemes operate on the principle of shared risk, fraud harms every single member by:

Driving up overall claims' costs
Reducing the availability of funds for genuine healthcare needs
Contributing to contribution increases
Placing long term financial pressure on the Scheme

For these reasons, Remedi has a zero tolerance policy on fraud. This protects honest members and ensures the Scheme remains fair, affordable, and sustainable.

Consequences of Fraud

Any member or provider found guilty of fraudulent activity will face serious consequences, which may include:

For members:

Termination of membership - fraud results in immediate removal from the Scheme.
Recovery of losses - any money paid out due to fraud will be reclaimed.
Legal or criminal charges - fraudulent claims violate South African law and can lead to prosecution.
Future medical aid difficulties - a fraud record can make it harder to join other schemes.

For providers:

Blacklisting and reporting to regulatory bodies
Removal from Remedi's provider network
Criminal prosecution

Fraud is taken extremely seriously because the consequences of ignoring it are even more severe for the Scheme and its members.

What You Can Do to Protect Yourself and Your Scheme

Every member plays a key role in preventing fraud. The actions you take, big and small, help keep contributions affordable and ensure your benefits remain available when you need them.

Here's how you can help:

Use your benefits honestly and responsibly

Only claim for services you have genuinely received. Never share your membership details with anyone.

Review your statements

Always check your claims statements and app notifications to ensure charges match the services you received. Report anything that looks unusual.

Be cautious with provider interactions

If a provider suggests claiming for something you did not receive, walk away and report the incident.

Report suspicious activity

If something feels wrong, whether from a provider, a family member, or another party, please report it anonymously through Remedi's fraud hotline or member support channels:

Toll-free phone number: 0800 00 45 00
SMS number: 43477
Toll-free fax number: 0800 00 77 88
Email: discovery@tip-offs.com
Post: Freepost DN298, Umhlanga Rocks 4320
Email forensics@discovery.co.za directly for an investigation into the matter

Together, We Safeguard Sustainability

Remedi exists for the benefit of all its members. By standing firmly against fraud and using benefits with integrity, we ensure that the Scheme remains strong, stable, and sustainable for years to come.

Your vigilance helps protect the Scheme for everyone. Thank you for partnering with us to protect your health benefits and each other.