Monday, July 4, 2022

Healthcare: Fraud, Waste And Abuse

Healthcare: Fraud, Waste And Abuse

TFSA is a specialist Forensic Investigations and Consulting practice that focusses on supplying services to the medical aid and other related industries. TFSA provides medical aids with comprehensive end to end solutions to identify, prevent and eradicate fraud within the schemes they operate.

Our team includes medical experts who work closely with our data analysts. One of the specialisations that set us apart from others is that TFSA is practically involved with the recovery of monies claimed due to over-servicing, on behalf of the medical aid schemes with whom we work. We further provide rehabilitation of errant practitioner services, where fraud has not necessarily occurred and criminal prosecution is impractical.

We have widespread experience in the fields of medical administration, investigative and legal sub-specialties. Our work in these areas draws throughout on our well-established relationships with the SAPS, international agencies, the NPA, the Board of Healthcare Funders, health care actuaries, and related statutory councils.

The success of TFSA with schemes such as GEMS, Medshield, Bonitas, Massmart Health Plan, PSEMAS (Namibia) and several others has led to a number of industry “firsts“. The successful conclusion of several such matters has set new benchmarks in medical aid forensics.

Our facilities and proven software capability enable us to run a completely confidential, anonymous, toll free hotline. This is an essential tool in the early identification of fraudulent practices as it relies on confidential member participation.

Real Time Claims Analytics

Due to the ever-evolving development of Artificial Intelligence as well as Machine Learning; TFSA during the first quarter of 2018 partnered with an industry leader in the field with specific experience in the healthcare industry.

The reason for this partnership was to enable TFSA to offer an independent world class AI & ML base that would not expose a client’s confidential client database and sensitive medical information to competitors.

By obtaining proper interface links to the Designated Healthcare Provider’s claims platform, the TFSA Claims monitoring tool can be implemented on a live feed with reports generated on a continual basis to the designated HCP’s Operational Staff. This is consistent with the requirements of the Medical Scheme’s Act, sect 59 (2) which allows for claims payment within 30 days from submission.

This unique feature would enable early detection of improper payments; predictive, accurate claims decisions and savings of millions.

We can assist the designated HCP to recover on their ROI from the payment integrity efforts with solutions that inter alia addresses:

  • Fraud and improper payments (waste and abuse). Detect improper payments before the money goes out the door, and get potential savings of millions of rands. Take an enterprise approach to detecting and preventing fraud, waste and abuse with a hybrid analytics solution.
  • Eligibility fraud. Determine eligibility of coverage in your various options to avoid unwarranted costs by using sophisticated analytical tools and a variety of data sources.
  • Enterprise case management. Manage investigation workflows, attach commentary and record financial information, such as exposures and losses using a holistic, structured case management environment.

Fraud, Waste And Abuse Campaigning And Training

TFSA has been an industry leader in the combatting of fraud, Waste and Abuse for more than 20 years. As such TFSA constantly identifies new trends or modus operandi and in turn develops counter measures in the fight against FW&A in the medical aid industry. By applying its extensive industry knowledge, contacts and intelligence networks proactively and reactively for its clients’ benefit TFSA has been able to achieve measurable inroads in the fight against FW&A. Further TFSA considers it as a moral obligation to educate members to identify FW&A which ultimately creates a sense of ownership of the scheme by the members.

Fraud Hotline

Fraud Hotlines have proven to be one of the more expedient and inexpensive whistle-blowing solutions to date, and have become an essential component to any fraud risk management strategy.

TFSA has a sub-contracting arrangement with an independent and objective service that affords employees and trading partners the opportunity to blow the whistle on unethical conduct in the workplace, in a confidential and secure manner.

TFSA are able to provide a dedicated call centre with full time forensic professionals 24 hours a day, seven days a week, 365 days a year. The forensic agents are able to handle all South African languages as well as an array of international languages.

In addition to hosting the “Hotline” and “Hotfax” mediums, the “Hotmail, Hotlink and Hotpost” mechanisms to facilitate secure reporting via the web and/or local postal service.


Our years of experience have proved that although powerful data analytics exist that enables prudent fiscal discipline of a scheme’s resources, nothing replaces the actual physical field work that allows a scheme to have first-hand knowledge of the existence of a practice, type of equipment being used and the actual demographics of where the service provider is based.

In order to maximise quality and efficacy, investigations are subdivided into:

  • Data Analytics: full analysis of a scheme’s claims data set highlighting the Risk Exposure.
  • Field Investigations: TFSA deploys qualified investigative teams to the different areas to conduct member interviews. This is often utilised by participating schemes as a value-added service whereby member sentiments are also gauged. Invariably, the service providers in a particular area are visited and informal practice inspections conducted.
  • FW&A Quantification and Recovery: Once an investigation has been completed, TFSA will, in conjunction with the client and their medical advisors quantify the losses incurred as result of FW&A and allow the service provider an opportunity to enter into a settlement agreement with the scheme.
  • Provider Engagement: TFSA ensures that the provider that is subjected to scrutiny is allowed an opportunity to respond to possible anomalies detected; and to explain the synergy of the practice. The few errant service providers are also allowed to rectify mistakes and continue to service the participating scheme’s members with a quality service.
  • Med e Data®: Is a comprehensive and effective forensic data analysis program that was developed by ourselves and it consists of combined experience, knowledge and case studies relating to specific investigations, fraud schemes, clinical notes etc. If required, TFSA can provide case specific analysis detailing focus points. These findings are based on comparative studies, clinical rules as well as interpretation of scheme Rules.
  • Litigation Support: TFSA has on hand experienced legal experts that assist the various Law Enforcement Agencies as well as designated Police Officers in matters of a more serious nature and where the law dictates criminal prosecution.