Fraud , Waste and Abuse : A success story
Sarah * is a stylish , proud mom of three . She has always fitted into a size 10 dress and enjoys spending her money on stiletto shoes . After the birth of her third child , she was struggling to lose the last few kilograms and was longing to fit into her pre-pregnancy clothes . Her friend , Caroline *, had a solution for her . Caroline informed her about a benefit that their medical aid provides , which covers slimming waist bands . She was so excited about this benefit that she shared the news with all her colleagues .
To make it even better , she met a fantastic dietician who went the extra mile to have the waist band delivered directly to your house and even allowed you to exchange it for a different size at no extra cost .
Sarah jumped at the opportunity and contacted the dietician on the same day to place her order . She was excited to receive delivery of the highquality waistband and decided to share the tip with even more colleagues : ‘ More people should know about the benefits that their medical aid offers .’
The Forensics Department noted a spike in dietician costs paid by the medical scheme . The sophisticated forensic tools flagged Mr . Adam ’ s * practice as a risk due to a number of factors including : The sudden increase in claims ; a high number of hours billed per day and ICDcodes billed being remarkably similar for each consultation . Following the analysis , the Forensic Analyst decided to digitally verify claims submitted with members directly .
The Forensics Department sent a message to Sarah to confirm whether she had consulted with a dietician named Mr . Adams during the month . Confused with the message received , Sarah had never met Mr . Adams , she asked her husband to assist .
Below is the email response from her husband :
Sarah and her husband were left speechless after the forensics team informed them that Mr . Adams was defrauding their medical scheme by claiming for consultations while only providing waist bands to members . Waist bands are not covered by the Scheme as it is not clinically appropriate and necessary .
In future , Sarah and her husband will review their membership statements in detail and report irregular claims to the Scheme hotline .
We urge all members to be more vigilant and to keep an eye on their membership statements and to report any charges that don ’ t make sense .
(* Member / provider name changed for confidentiality purposes )
Bonitas Member Magazine Issue 4 | 2021
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