Implications of fraud
The GEMS Fraud Forum will investigate all allegations of fraud thoroughly and effectively. In cases where it is confirmed that a member of healthcare provider has been involved in fraudulent practices, the Scheme reserves the right to impose certain sanctions.
In the case of healthcare providers, the following sanctions may be imposed:
- Reversal of all irregular transactions (e.g. claims); and
- Placing a provider on indirect payment from the date the Scheme approves the recommended sanction and/or;
- Reporting a provider to the relevant regulatory body and;
- Recovery of losses through civil or criminal process, and/or
- Proceeding with a criminal case, depending on the Scheme decision; and
- Removal of the provider from any GEMS network for a period of 12 months.
In the case of registered members, the following sanctions may be imposed:
- Termination of membership; and/or
- Proceeding with a criminal case; and
- Recovery of losses; and/or
- Reporting the member to their employer or pension fund where an employer subsidy is paid to the Scheme on behalf of the member.