fraudrisksolutions.co.za

I am a member of the ACFE (Association of Certified Examiners), HFMU (Healthcare Fraud Management Unit), a qualified internal auditor and with 26 years’ experience in the Healthcare industry. My diverse skill set of industry knowledge, expertise gained in the Fraud and Risk environment together with my strong technical system skills have led to many career highlights. I am comfortable and proficient as both a team member or team leader, working independently or with a team to achieve results. 

At Metropolitan Health Group, I was tasked to oversee, manage and implement the automation of the current clinical system that allowed for preventative, comprehensive and accurate risk findings for business review and intervention. Another achievement at Metropolitan, saw me tasked to perform a risk assessment on the banking and payments platform with the aim of providing a streamlined risk mitigated solution to allow for a more effective, efficient payments payment platform. 

At Liberty Health I drafted a Fraud Risk Management plan to implement the full fraud risk capability for its Africa regions, including initiating the inaugural Africa Healthcare fraud forum. Outside of my Fraud environment, and because of my technical knowledge, was tasked to review the current Quality Assurance standards at Liberty, identified process, system gaps and implement risk mitigation controls.

Currently serving as a Health Insurance Forensic Auditor and Clinical Adviser, he brings over 17 years of extensive experience as a primary care physician. His professional journey includes more than 9 years as a Medical Officer and Program Manager with the US government agency Peace Corps in Mozambique, where he honed a deep understanding of the Mozambican health system both private and public sectors.

His diverse skill set encompasses healthcare data analysis, health facility management, coordination of local and international medical evacuations, emotional support, short-term mental health counseling, and the management of acute, episodic, and chronic illnesses. He possesses solid expertise in the implementation and utilization of telehealth services and electronic health records. In addition to his clinical and advisory roles, He is a dedicated Patient Safety and Quality Improvement Specialist.

Dr Carlos is also a Certified Member of the Data Safety Management Board for the Southern Africa Region SPEAC Project, demonstrating his commitment to advancing healthcare standards and ensuring data safety.

Our fraud risk assessment has identified a general weakness in the internal controls relating to Hospitalisation requests. Our findings indicate a lack of adequate scrutiny of clinical evidence provided in pre-authorisation requests, resulting in significant financial losses to the health insurer. Our recommendations included the requirement to provide the providers clinical motivation, clinical history and patients claims history. 

Our Fraud Detection further identified inconsistencies between what was authorised and what is claimed by the healthcare provider. We predict that between 30-35% of a client's total claims paid can be reduced by adequate clinical audits of hospital claims. 

Historical data suggest that members attribute about 30% of the total fraud loss experienced in the health industry. A leading fraud type unfortunately relates to member claim refunds. Our fraud Investigations have confirmed that the root cause relates to false claims submitted by members, claim invoices with no or invalid proof of payments or claim values that have been altered to a higher value. 

Our Claim audits have identified weak business controls and a lack of an adequate oversight function to mitigate the fraud risk.

Our Fraud Detection has identified providers with unusually high average costs per claim or per patient driving claim costs. This results in significant negative impact on a clients claim loss ratio. 

Our solution to mitigate against the fraud risk, is to create a robust and proactive fraud detection capability to flag high costing providers for further scrutiny, identify the specific services requiring re-negotiation at lower prices which has resulted in a reduction in provider and total claims costs.