Source: The Herald – Breaking news.
Mr Stanford Sisiya 
Rumbidzayi Zinyuke, Senior Reporter
Zimbabwe’s health insurance sector has recorded a surge in fraud cases, with 1 577 incidents reported in 2024 alone. According to the Association of Healthcare Funders of Zimbabwe (AHFoZ), the rise in fraud cases has led to the blacklisting of 13 service providers as part of efforts to curb financial losses and maintain the sustainability of medical aid societies.
The fraud emanates from service providers, including doctors, pharmacists, and laboratories, who claim money for procedures or services not rendered. AHFoZ board chairperson, Mr Stanford Sisiya, acknowledged the severity of the issue, saying fraud in the health sector was becoming increasingly sophisticated.
“It’s a very big issue. Our systems are supposed to pick up those fraud cases, and they can automatically reject a claim and give a reason for the rejection. We are constantly developing countermeasures to combat fraud, but then you actually realise that the service provider can also be innovative around it because everyone wants money,” he said.
AHFoZ is responsible for accrediting healthcare providers and institutions and seeks to address industry issues such as standardising tariffs, establishing and publishing fee structures, as well as fighting fraud. Mr Sisiya said the association had set up a risk management committee that monitored trends, and information on any suspected fraud was flagged while investigations were conducted.
However, rather than outrightly banning flagged providers from accepting medical aid, he said AHFoZ prioritised rehabilitation and financial recovery. “The way we are running the industry right now; we have been trying not to punish or abolish providers. I think for us the priority is to ensure that we rehabilitate them, and if there’s going to be any recovery, then we recover for anything that they would have taken from the medical aid inappropriately. So, we are not going to be withdrawing the AHFoZ number from that provider, because once it’s withdrawn, we’re not able to claim anything. So banning is a last resort,” he said.
However, according to AHFoZ chief executive officer Ms Shylet Sanyanga, the flagged cases are not always outright fraud, as some are classified under financial misconduct. “There is outright fraud, which is a crime and can be reported to the police. Then there is abuse, misuse, and there is error. Sometimes there is a very thin line. This is why we have a team of trained people who actually assess these claims, and they can identify that this is fraudulent or that this is just abusing the system. Sometimes abuse is by the service provider; sometimes it’s by the card-carrying member themselves,” she said.
She said this was why advanced data analytics play a crucial role in identifying fraudulent claims, linking service providers to suspicious patterns, and flagging irregular activities. Only 10 percent of the country’s population is insured with medical aid societies, leaving over 90 percent paying for healthcare services out of their own pockets.
Despite medical aid being out of reach for many, Ms Sanyanga said medical aid tariffs must balance affordability for members while ensuring healthcare providers receive fair compensation.
“Apart from conducting research, we also engage healthcare service providers and negotiate with them when coming up with tariffs. We check what is happening in the region, but we always try to come up with tariffs that are suitable for our environment. So, when we negotiate with the healthcare service providers, we are trying to strike a balance so that at least the healthcare service providers are paid but the contributing member should still be able to afford the contribution,” she said.
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