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Fraud, Waste and Abuse


Health Care Fraud and Abuse

The private healthcare industry is increasingly compromised by irregular claims being submitted by medical scheme members as well as healthcare service providers. It is in

the interest of members of medical schemes and all industry role players, including healthcare professionals to limit financial losses arising from fraud, waste and abuse.

GEMS takes its responsibility seriously to protect the integrity of the care its members receive, its Healthcare Options, and member funds. Healthcare Fraud - Knowingly submitting,

or causing to be submitted, false claims or an intentional misrepresentation of the facts in order to access payment of a benefit to which one would otherwise not have been entitled.


Please read more on the Fraud Waste and Abuse Policy

Gems

Billing for items and services that are not medically necessary

Gems

Misrepresentation of the type or level of service provided

Gems

Seeking payment or reimbursement for services rendered for procedures that are integral to other procedures performed on the same date of service (unbundling)

Gems

Misrepresentation of the individual rendering service

Gems

Seeking increased payment or reimbursement for services that are correctly billed at a lower rate (up-coding)

Gems

Billing for items and services that have not been rendered

Waste and Abuse - Claiming for healthcare treatment and services that are not absolutely medically necessary, including any form of over-servicing or over-charging of a patient, and that may objectively be considered unethical or unconscionable or contrary to best practice principles.

Fraud
Examples of healthcare Waste and Abuse are:

Misusing codes on a claim;
Charging excessively for services or supplies; and
Billing for services that were not medically necessary.
Both fraud and abuse can expose a provider or member to criminal and civil liability.

How can members and healthcare providers help Prevent Fraud, Waste and Abuse?

Validate all member ID cards prior to rendering service;
Ensure accuracy when submitting bills or claims for services rendered;
Avoid unnecessary drug prescription and/or medical treatment;
Check your statements regularly - Make sure claims paid match the services you and your family received; and
Report lost or stolen prescription pads and/or membership card.

phone

Report all suspicions of fraud, waste and abuse by :

Call the anonymous  24 hour toll free GEMS Fraud Line Service: 0800 21 2202

Email:office@thehotline.co.za

Faxing: 0867 26 1681

 

 

Posting information to :

The Fraud Services Manager
119 Witch Hazel Avenue
Highveld Technopark
Centurion
P.O. Box 10512,
Centurion, 0046

 

 

Fraud articles

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Former pharmacist gets suspended sentence

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Can a medical scheme fire a member for fraud?

If you failed to tell the whole truth about your medical history in your application, can your scheme terminate your membership?

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Medical scheme

lifts lid on fraud amounting to millions

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