Home Forensics Reactive Forensics Medical Scheme Fraud

Medical Scheme Fraud

Our medical schemes forensics team is well equipped to provide solutions to the most common acts of medical scheme abuse.

The SizweNtsalubaGobodo forensics governance offering ensures the correct calibre of candidates are appointed to the governing structures of medical schemes, equipping and capacitating boards of trustees, audit committee members and other governance structures with the necessary support and expertise to identify and act decisively towards eradicating incidences of medical aid abuses.

Pro-active Medical Schemes Forensics

  • Pro-active trend analysis to identify and mitigate prevalent trends in claims processed by specific disciplines;
  • Fraud risk analysis of control environments in the administration of claims and the identification of threats that increase the possibilities of coding and clinical exceptions and anomalies;
  • Fraud awareness workshops to educate schemes members and healthcare providers around fraudulent transactions and various other medical scheme abuses; and
  • Training of in-house forensic teams on investigative methodology, governance forensics and pro-active forensics under the umbrella of SizweNtsalubaGobodo’s The Forensic Institute.

Reactive Medical Schemes Forensics

  • Investigation of incidents of over-servicing, billing for services not rendered and use of invalid tariff
  • codes by healthcare providers (doctors, pharmacies and hospitals);
  • Investigation of the abuse of benefits, kickbacks and the fraudulent use of medical benefits by scheme members;
  • Investigation of collusion between employees of medical schemes/administrators and members or healthcare providers to derive undue benefits; Investigation of the role of other parties in the abuse of medical schemes benefits, including abuse by unauthorised third parties, brokers and etc; and
  • Litigation support in terms of civil recoveries, as well as expert case witness support in court.

Governance Forensics

Trustee Election Solutions

  • Preparing electoral officers for Trustee elections
  • Conducting probity checks on Trustee candidates
  • Facilitation of Trustee elections; and
  • Electoral officer service support.

Governance Solutions

  • Governance assessments and review of integrity structures;
  • Development of governance framework;
  • Directors and audit committees support in detecting and preventing breaches in governance structures;
  • Investigation of allegations relating to trustees and top management.

Statutory Solutions

  • Administration support to schemes in distress;
  • Trustee performance management monitoring; and
  • Statutory enquiries and appointments in terms of the Medical Schemes Act.