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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, Waste and Abuse Hotline : 0800 21 2202.

Email:gems@thehotline.co.za

Website: https://www.thehotline.co.za/report - Use 0800 212 202 to report

Mobile application: Vuvuzela Hotline app  - Download from play store, use 0800 212 202 to report

Faxing: 0867 26 1681

SMS: 30916

 

 

Posting information to :

The Fraud Services Manager
P.O. Box 10512,
Centurion, 0046

 

 

Fraud articles

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