Health services provider Corporate 24 allegedly duplicated claims, inflated service tariffs and falsified members’ signatures, prejudicing medical insurance giant Cimas of US$41 250, it has emerged.
The allegations are contained in a forensic audit report signed off by audit firm Grant Thornton South Africa’s director and head (forensics), Vernon Naidoo, on September 30, 2016.
The auditors recommended Cimas report the suspected fraud to the ZRP Serious Frauds Squad for further investigation and possible prosecution.
Investigators revealed that out of 352 suspicious claims that Corporate 24 made to Cimas, the latter could have been prejudiced of US$41 256.46.
The forensic investigation began on May 12, 2016 after Cimas had raised suspicions regarding Corporate 24’s dealings.
According to the report, auditors determined that in some instances, Corporate 24 claimed payment for the same services multiple times.
Some claim numbers, values and signatures allegedly differed.
Investigators from Safeguard Security tracked down some Cimas members to validate treatment, tests and drugs charges, and this opened a can of worms.
Part of the report reads, “In some cases, members stated that the claim had been duplicated where they were shown more than one claim with the same details but slightly different admit/discharge times and/or medical items such as gloves and cannulas.”
Investigators also unearthed 14 signatures that were different from those on claim forms and on Cimas records.
Safeguard Security investigators cross-checked 24 suspicious signatures and discovered that 10 of them had been disowned by Cimas members.
The report also says: “The value of these claims is US$1 949.91. Another member disputed the service which is valued at US$US117.34. In cases where the signature has been confirmed as fraudulent, it could mean that; the claim is fraudulent and that Cimas has been prejudiced to the value of the claim,” noted the Grant Thornton auditors.
Forensic investigators pointed out that a data analysis by Data Africa on 43 high value claims revealed that Corporate 24 forms stated that patients were treated for less than two hours.
However, the health services firm applied Association of the Healthcare Funders of Zimbabwe (AHFoZ) tariff code 02262 which is a more expensive tariff, thereby prejudicing Cimas of US$3 499.25.
An analysis of the use of Modifier 51 in laboratory and radiography tests also showed that 118 claims were investigated for being non-AHFoZ compliant, resulting in Cimas being prejudiced of US$9 358.
Corporate 24 was also allegedly caught charging emergency rates for non-emergency situations.
The report continues: “In one particular case in respect of over-servicing, for example, a patient visited Corporate 24 because she had an asthma attack. During our interview with her she denied having received any of the drugs listed on the claim form and indicated that the treating doctor then requested her to go for an emergency pregnancy scan and emergency blood test.
“An independent expert — medical practitioner has reviewed the claims under investigation from a diagnosis and treatment perspective and has concluded that in the majority of the claims reviewed evidence reflects over treatment and/or over-servicing.”
Forensic investigators established that Corporate 24 deliberately attempted to defraud Cimas by issuing dodgy cash receipt vouchers for amounts that were never paid to Corporate 24 by Cimas members.
In addition, there were cases where information was being overwritten or manually altered by Corporate 24 to overcome the initial reason for claims rejection by Cimas.
Auditors said, “There appears to be reasonable suspicion of claims related fraud and forgery in relation to some of the Corporate 24 claims identified as suspicious. There are indications from the destruction of evidence and the VSA that there are at least nine (9) Cimas staff who appear to be involved in fraudulent and/or corrupt activity and this matter should be investigated further. There are a number of system and internal control weaknesses within Cimas which require urgent improvement.”
Cimas, which is Zimbabwe’s second-largest medical aid society after Premier Service Medical Aid Society, has been locked in a payment dispute with Corporate 24 since 2015.
Contacted for comment yesterday, Corporate 24 group chief executive Dr Mike Joka requested written questions after which he promised to respond tomorrow.
He said, “Will check my mail and revert on Monday.”