A radiologist with a private clinic yesterday appeared in court for allegedly defrauding Premier Service Medical Aid Society (PSMAS) of $14 000 from 2021 by charging the medical insurance company for services it was not supposed to pay for.
The clinic is a service provider registered for PSMAS members.
Tinaye Harold Pedzisayi (34) from Hillpaul Health Scan Clinic appeared before Harare regional magistrate Mr Stanford Mambanje charged with fraud.
He was granted $500 000 bail.
Prosecuting, Mr Tawanda Nyandoro, alleged that PSMAS registered several radiologists nationwide to offer specialist services on its behalf, including radiography, ultrasound and x-ray scans.
Procedurally, PSMAS members with related problems would be referred to the registered radiologists by a doctor and the specialist would then claim their agreed fees from PSMAS through codes 76780, 76831 and 98206.
The Association of Health Care Funders of Zimbabwe (AFhOZ) was quite clear that Code 76780 was not to be claimed with either code 76831, there for female patients, or code 98206 for male patients.
The court heard that sometime in 2021, PSMAS engaged the services of RBM Auditors who carried out a forensic audit covering a period extending from 2015 to 2022 and unearthed several frauds, including those allegedly fraudulent claims by Pedzisayi between April and November 2021.
He rendered some ultrasound scans, pelvis and prostate assessment services to different PSMAS members and these services were all covered by code 76780.
But instead of claiming the services using code 76780, Pedzisayi claimed undue fees using other code 76871 yet they were not claimable together with code 76780.
Where one received service under code 76780, they were not supposed to be charged for code 76871 and as such, the doctor was not supposed to claim the fees.
Due to his misrepresentation, PSMAS effected payments into Pedzisayi’s bank accounts thereby suffering a prejudice of $14 426. – The Herald
