Investigation & Verification of Insurance claims

DANIEL VAN COLLER (Principal)
Cell:       083 278 3505
eMail:   daniel@scivs.co.za

WESSIE VAN DER WESTHUIZEN
Cell:      082 578 6525 / 082880 9577
eMail:   wessie@scivs.co.za

Healthcare claims - South Cape Insurance Verification Services

The following frequent fraudulent claims occur in the Healthcare environment:

  • Doctors submit claims for services that have not been rendered to patients
  • Dispensing doctors and pharmacies provide members with low cost generic medicines and claim for higher cost brand name medicines
  • Doctors provide fraudulent sick notes to members and then claim for a consultation from the scheme
  • Pharmacies sell cosmetics and other “front shop” items to scheme members, and submit fraudulent claims for “medicines supplied” to the scheme
  • Members, in collusion with doctors and hospitals, submit claims for false hospital admissions, in order to benefit from the claims payment
  • Members forge and submit claims for services supposedly rendered by healthcare professionals, but which were never actually rendered
  • Ghost medical aid submissions (Identity theft)

The financial consequences of this abuse include:

  • Possible premium increases
  • More thorough validation processes for hospital authorisation requests
  • More stringent criteria for accepting members to a scheme
  • And for perpetrators, criminal prosecution

Fees – to be agreed with the Insurer or supplier