GETTING CAUGHT IN THE HEALTHCARE INDUSTRY

WHAT COULD THE MOTIVATION FOR HEALTHCARE FRAUD BE?

WHAT IS THE PROBLEM?

“At the heart of the problem is the diversification of organised

crime. Criminals can also be savvy at business. They need to

diversify because they don’t want just one scam to bring in all of

their revenue; it may be shut down, they may have a slow month

and then they’ll have a cash flow problem,” says Downey.

John Downey, Head of Security, Braintree payment company.

E-article: Cyber-attacks: we need to talk about fraud

FEE FOR SERVICE MODEL

OVER-SERVICING

FAILURE TO FORM A

WHAT IS THE PROBLEM?

Healthcare fraud, waste & abuse is one of the fastest growing crimes in South

Africa today

Costing the industry billions and increasing the cost of healthcare

Tantamount to that of organized crime

Operating in silos

THE FINANCIAL IMPACT IN THE ABSENCE OF COLLABORATION

Scheme A Scheme B Scheme C

Jan R 25 563.28 R 0.00 R 0.00

Feb R 32 409.29 R 0.00 R 0.00

Mar R 79 797.49 R 0.00 R 0.00

Apr R 682 159.79 R 0.00 R 0.00

May R 111 593.10 R 0.00 R 0.00

Jun R 0.00 R 374 453.50 R 0.00

Jul R 0.00 R 296 417.88 R 0.00

Aug R 0.00 R 12 293.72 R 15 367.37

Sep R 0.00 R 10 756.09 R 80 655.63

Oct R 0.00 R 0.00 R 469 446.97

Nov R 0.00 R 0.00 R 85 767.22

Dec R 0.00 R 0.00 R 11 944.81

WORKING IN ISOLATION

CONSOLIDATION & COLLABORATION

Collaboration through a

collated, summarised &

high level claims data

approach to identify

these patterns is the next

generation of fraud

detection and prevention.

FRAUDSTERS DO GET CAUGHT

August 2018: Mr Wandile Theophilus Mashego, an audiologist and speech therapist practising in Pretoria, was found guilty of 259 counts of medical aid fraud and 1 count for contravening Section 66 of the Medical Schemes Act. Mr Mashego was ordered to pay back R506k as well as being subject to stringent conditions including house arrest, a suspended prison sentence, community service and correctional supervision.

Last week: Mr Henny Tinyiko Mavasa, was found guilty of 60 counts of medical aid fraud and 60 counts for contravening Section 66 of The Medical Schemes Act. The case was brought against him by Bonitas and he was sentenced in the Johannesburg Specialised Commercial Court. He had been submitting fraudulent claims on members over a period of two years. Mavasa pleaded guilty under Section 105A of the Criminal Procedure Act 77 of 1951 and was sentenced to a fine of R60k or 3 years imprisonment. He was also sentenced to a further 3 years imprisonment, suspended for 5 years. It was noted by the Court that the guilty party had already paid R87k back to Bonitas, which was the amount the criminal case had proven beyond reasonable doubt. FA News October 2018

FRAUDSTERS DO GET CAUGHT

Half-a-billion rand. That is what Discovery Health administrators claimed it has saved Discovery Medical Aid – and other medical aids – by uncovering fraud and recovering ill-spent money. But Discovery Health said there was probably a few more billion rand wasted through fraud that is never uncovered each year. The R568-million recovered was up from R405-million in 2016‚ the administrators said on Friday.

Last year medical aid administrator Medscheme detected R300 million worth of fraudulent claims, it reported this week.

WHEN COLLABORATION KICKS IN

TOTAL INCAPACITATION - INSURER

CLAIMED FOR SERVICES RENDERED –

MEDICAL SCHEME

28/4/2010 – 12/5/2010 28/4/2010 & 29/4/2010

26/5/2010 – 2/6/2010 1/6/2010 & 2/6/2010

11/7/2010 – 18/7/2010 15/7/2010

10/9/2010 – 26/9/2010 16/9/2010

23/10/2010 – 2/11/2010 25/10/2010

20/11/2010 – 12/12/2010 29/11/2010 & 8/12/2010

Falsified personal claims – R 11 000.00 Attempting to substantiate a chronic condition Forensic handwriting examiner – court appointed Insurer & medical scheme = United Front

HEALTHCARE FORENSICS GETTING STRONGER THE PRESENT

AI models – early identification & case management of high-cost outliers Sophisticated algorithms World-leading software tools – behavioural analytics Clear policies Zero tolerance approach Hotlines for reporting Collaboration with Law Enforcement Agencies & Regulatory bodies Active intervention Termination of membership – evidence of collusion

THE FUTURE

Increased awareness Centralised repository Measuring the holistic extent of the problem Improved collaboration between all parties Harsher sanctions

55555

Banks & Financial Institutions

Unsecured Lenders Retailers & Other Motor, Insurance & Telco’s

Screening & Bureaux Services

Standard Bank Old Mutual Finance

Truworths Mercedes Benz FS Compuscan

First National Bank Capfin Woolworths Financial Services BMW FS Managed Integrity Evaluation (MIE)

ABSA Bayport FS JDG Trading SA Taxi Development

LexisNexis Risk Management

Nedbank Real People Mr Price Group MTN Consumer Profile Bureau (CPB)

African Bank Get Bucks Lewis Stores Cell C Inoxico

Capitec Mazwe Financial Services RCS Cards Telesure Group Services Affiliated Members

Bank of Athens Edcon (ABSA) (Standard, Absa, FNB and Nedbank Insurance)

Trans Union, Experian, XDS

SA Home Loans Teljoy Badger Holdings ICB, SABRIC

Al Baraka Bank Multichoice Afrocentric Health Public Sector Partners

Thyme Bank Home Choice SARS

Sasfin Bank The Foschini Group Financial Intelligence Centre (FIC)

Investec Bank Ltd. MBD Credit Solutions

South African Reserve Bank (SARB)

Ubank Department of Home Affairs (DHA)

Discovery Bank

50 MAJOR BRANDS

RECIPROCAL SHARING OF DATA….“BRING & BRAAI”

CRIMINALS DON’T WORK IN SILOS

‘ALONE WE CAN DO SO LITTLE, TOGETHER WE CAN DO SO MUCH’

HELEN KELLER

BRIDGE THE GAPS BETWEEN SILOS

LYNETTE SWANEPOEL

SAFPS – MANAGER, NEW BUSINESS, HEALTHCARE & INSURANCE ACFE SA – CHAIR, HEALTHCARE FORUM

TEL: 082 4900 382

EMAIL: LYNETTES@SAFPS.ORG.ZA