The Fraud & Abuse Department

Frequent fraud risk assessments are designed to identify and evaluate risk factors that could enable fraud to occur. These assessments keep us abreast of new techniques applied by fraudsters and result in a regular update of control policies and procedures. We invest in fraud detection programs and controls to detect fraudulence after reimbursement. All programs and controls are embedded in a way that the dignity and privacy of the patient remain respected.

  • Continuously updates fraud policy and strategy;
  • Deals with the operational work involved in the thorough investigation of a claim once it has been flagged as a potential fraud claim;
  • Collects evidence to substantiate sanctions;
  • Takes the necessary action to obtain a successful recovery of the defrauded money and to consequently develop an anti-fraud culture amongst the members of the health plan;
  • Provides fraud reporting to the clients;
  • Continuously improves the fraud detection mechanisms for retrospective identification of fraudulent cases.

Components of Counter Fraud Approach

Measures taken to prevent, deter and detect fraud fall into three categories:

  • Establishing a general control environment;
  • Developing specific measures for fraud prevention and pre-payment fraud detection;
  • Developing specific measures for post-payment fraud detection.

Our services

Medical network

  • Negotiated agreements
  • Medical providers
  • Dedicated website for providers

Technical & Actuarial

  • Monitoring of portfolio

Advisory Board

  • Comparison MQ/ diagnoses
  • Prior agreements checks
  • Payment ceiling (Price List / R&C)


  • Administration tool configured to detect fraud
  • Dedicated team