FRAUD BE? - South Africa · 2018-11-21 · Unsecured Lenders Retailers & Other Motor, Insurance &...
Transcript of FRAUD BE? - South Africa · 2018-11-21 · Unsecured Lenders Retailers & Other Motor, Insurance &...
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
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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: [email protected]