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.

Examples of healthcare fraud are:

 

  • Misrepresentation of the type or level of service provided;
  • Misrepresentation of the individual rendering service;
  • Billing for items and services that have not been rendered;
  • Billing for items and services that are not medically necessary;
  • Seeking payment or reimbursement for services rendered for procedures that are integral to other procedures performed on the same date of service (unbundling);
  • Seeking increased payment or reimbursement for services that are correctly billed at a lower rate (up-coding). 

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.

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.

Report all suspicions of fraud, waste and abuse by:

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

Emailing: gems@thehotline.co.za

Faxing: 0867 26 1681

Posting information to:

The Fraud Services Manager
PO Box 21076
Valhalla
0137

 

 

Contact us

Know of any fraud?
Call the anonymous 24 hour toll free GEMS Fraud Line Service

0800 21 2202.
gems@thehotline.co.za
0867 26 1681

Post information to:
The Fraud Services Manager
PO Box 21076
Valhalla
0137

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Email: media@gems.gov.za 

Contact: 011 469 3016