Global Solution Providers   *  Advisory   *   Anti-Fraud Training   *   Certifications

Examining Foreign Health Insurance Claims from Africa for Fraud (A Guide for Claims Examiners and Investigators Worldwide)

BOOK

 

Examining Foreign Health Insurance Claims

From Africa For Fraud

 

 

 

                                             TABLE OF CONTENTS

 

 

Introduction

 

Aspects of Health Insurances

 

Section A. HEALTH CARE SERVICES AND MEDICAL CHARGES

1.      Hospital Structure

2.      Hospital Facilities

3.      Common Illnesses in Africa – Treatment and Charges

 

Section B. EVALUATING CLAIM DOCUMENTS

4.      Claim Forms

5.      Hospitalization

6.      Are the hospital and paramedical centers registered?

7.      Is the physician a registered medical practitioner?

8.      Reviewing claim documents (medical report, bill,

treatment records)

9.      Police documents (Police extract, Abstract, and Report)

 

Section C. INDICATORS OF FRAUDULENT CLAIM DOCUMENTS

10.  Indicators of Fraudulent Claims

 

Section D. NATURE OF FRAUDULENT CLAIMS

11.  Fabricating documents of non-existing providers (medical

clinics, hospitals, and paramedical establishments)

Case Studies (2)

12.  Forgery of documents of existing providers (medical

clinics, hospitals, and paramedical establishments)

Case Studies (3)

13.  Policyholder conniving with physicians and medical

personnel

Case Studies (4)

                                                                                                                             

Section E. EXAMINATION OF MEDICAL REPORTS, BILLS, AND

                   TREATMENT RECORDS IN FIVE (8)

                   FRAUDULENT CLAIMS WITH MEDICAL CONSULTANTS

14.  Examining medical reports, bills, and treatment records

 

Section F. FRAUD INDICATORS SCALE (FIS)

                   INDICATIONS FOR INVESTIGATION

15.  Fraud Indicators Scale (FIS) /

Indicators for Investigation Scale

16.  Five Working Examples using the

         “Fraud Indicators Scale (FIS) /

           Indicators for Investigation Scale”

17.  Instructing Investigators – the challenges

 

Appendices

 

Appendix 1

 

Minimum Basic Facilities and Staff Complement

(Common requirements in most African countries) for:

a)      Private medical clinic

b)     Private hospital

c)      Private medical laboratory center

d)     Private physiotherapy (physical therapy) center

e)      Private radiographic (X-ray) center

 

Appendix 11

 

                   55 African countries: The name and capital city,

                   official language(s), currency and code, and the

 

                   telephone code