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