Incorporating TRAVEL FRAUD   *   Global Solution Providers   *  Advisory   *   Training   *   Certifications

EXAMINING FOREIGN HEALTH INSURANCE CLAIMS FROM AFRICA FOR FRAUD

(A Guide for Claims Examiners and

Investigators Worldwide)

 

-Based on investigations conducted in Africa for insurers, HMOs and travel insurance companies in the United States, Canada, Europe, Asia, and the Middle East

 

Authors

 

Israel Obiora Mbachu, CFE, CII

Stella A. Obiora-Mbachu, Ph.D., CFE      

 

First Published in 1999

Revised and updated in 2016

Scheduled release date, June 30, 2016

 

COMMENTS

 

“Israel, I was to undertake some training for a few of our trainees and needed to read your book once again. In fact, no Claims Examiner will read that book and pay a single fraudulent claim from Africa. Each time I read the book, I see insights that I overlooked the last time I read it.”

 

-       Senior Investigator, Insurance Investigation Services

Major insurance company in Canada

 

This book contains up-to-date information for the professionals as follows:

 

·         Life and Health Insurance Claims Examiners and Specialist Investigators

·         Travel Insurance Claims Professionals

·         Insurance and Fraud Investigators

·         Loss or Independent Adjusters

·         Private Investigators

·         Investigators in Insurance Fraud Bureaus

·         Insurers’ Medical Consultants

·         Insurance Attorneys and Solicitors

·         Employee Benefits Managers in organizations

·         Law Enforcement Officers and Prosecutors

 

The book is updated whenever there are developments requiring changes in the contents. Neither the Publisher nor the authors assume any responsibility or liability for the use or misuse of information contained in the publication.

 

Health insurance claims covered in this book were taken from cases under such policies as follows:

 

·         Individual Health Insurance

·         Travel Insurance (Medical Expenses)

·         Personal Medical Insurance

·         Critical Illness / Care

·         Living Needs Benefit Insurance

·         Group Health Insurance

·         Hospital Confinement / Indemnity

·         Workers’ Compensation Insurance

·         Disability Insurance

·         Personal Accident Insurance

·         Personal Accident Liability

 

 

TABLE OF CONTENTS

 

Introduction

 

Aspects of Health Insurance

 

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 and licensed medical practitioner?

8.    Reviewing the claim documents (medical report, bill, and 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 notes (10)

12. Forgery of documents of existing providers (medical clinics,

hospitals, and paramedical establishments)

Case notes (10)

13. Policyholder conniving with physicians and medical

Providers

Case notes (10)

 

Section E: EXAMINATION OF MEDICAL REPORTS, BILLS, AND

                  TREATMENT RECORDS IN FIFTEEN (15)

                  FRAUDULENT CLAIMS

14. Examining medical reports, bills, and treatment records

 

Section F: INDICATIONS FOR INVESTIGATION

15. Indicators for Investigation Scale

16. Ten Working Examples using the

            “Indicators for Investigation Scale”

17. Instructing Investigators – the challenges

 

Appendices

 

i)     Currencies(Monetary units of 55 African countries)

ii)    Minimum Basic Facilities and Staff Complement

(Common requirements in most of African countries) for:

a)    Private medical clinic

b)    Private hospital

c)    Private medical laboratory center

d)    Private radiographic (X-Ray) center

e)    Private physiotherapy (physical therapy) center


Scheduled release date, June 30, 2016