Our MRA is an ex ICU sister who entered the field of forensic and fraud investigation a number of years ago. Her expertise has been applied to the interpretation of and commentary on medical data.
She has completed a large scale investigation of fraud amount to millions of rands by a syndicate within a government agency and has assisted Insurers with reviewing the claims for their hospital cash plan policies as well as assisting with life insurance and funeral policy investigations and underwriting.
Governmental agency investigation
Medical expert for the investigative team – verifying and interpreting medical data related to fraudulent claims by analyzing medical reports and patient files, analyzing invoices compared to injuries and ensuring compliance with gazette tariffs.
Report writing whereby the injury / illness / disease is discussed, comparisons between the invoiced care and the actual care the patient received made, discussed tariff compliance and exceptions, invoice data analysis and conclusions on the validity of the claim.
Verifying the following:
- Medical processes and medical service providers using multiple sources
- Acquiring contact details of and relevant information of the medical service providers
- Determining the capacity each service provider has to invoice against certain codes
- Analyzing medical documents and determining whether or not hospitalization was justified and necessary and also commenting on the length of confinement
- Comparing the diagnosis with treatment the patient received and coming to a conclusion depending on the needs of the
Analysis of medical documentation for the purpose of determining if hospitalization and length of hospitalization was justified by the diagnosis made or treatment received.
Commentary made on medical reports and their supportive effect on the diagnosis or treatment received during the hospitalization.
Mandate – determinations regarding hospitalization supported by rationale. Skill set required for the above:
- Document sourcing
- Document analysis
- Rational thinking
- Application of medical insight
- Generating comprehensive reports
In addition to the above, investigation of claims for various insurers ensure the acquisition and development of various other skills:
- Statement taking
- Scene investigations