Fraud Prevention

Centralized control over all AlphaScript Network Providers:

The web-based integrated nature of the AlphaScript Pharmacy Management System allows AlphaScript to hard-code front-end rules that enforces discipline and compliance onto the AlphaScript Network Providers;

The provisions of the Three-Way Service Level Agreement between AlphaScript, the AlphaScript Network Provider and the patient and the obligations imposed upon the AlphaScript Network Provider read together with the AlphaScript provider Network Accreditation Regulations as contained in Annexure H thereof, further allows AlphaScript to govern and regulate the performance of the AlphaScript Network Provider to the extent that AlphaScript can within its rights dis-accredited an offending AlphaScript Network Provider subject to the outcome of a disciplinary enquiry;

Fraud Management Policy:

AlphaScript is desirous to stamp out any form of fraud, abuse or misuse of the medical scheme’s valuable resources and will actively participate in any initiative that aims to achieve the same. AlphaScript will henceforth make it available to attend fraud framework meetings on an urgent basis;

AlphaScript will conduct a quarterly risk assessment to investigate whether any asset misappropriation, corruption, fraudulent conduct or any material internal irregularities have taken place, based on its current fraud framework but also supplementing the same with any specific areas of evaluation by the medical scheme;

AlphaScript will align its internal evaluation processes to the anti-fraud charter of the medical scheme to mitigate fraud and corruption risk by reporting any area(s) of non-compliance to the medical scheme.

AlphaScript, within the scope of our business, currently uses the following 10 point fraud protection plan to create and maintain a controlled environment which can reduce or control the associated risk of such fraudulent incidents:

  • Do any key employees have a close association with any vendors?
  • Do any key employees have any outside business interests that might conflict with their duties?
  • Pre-employment background checks are done to identify any previous dishonesty or unethical behaviour?
  • AlphaScript provides a confidential whistle-blower system to report to report the violation of ethics and anti-fraud policies;
  • financial controller system is in place to check employees that works with accounting duties;
  • Credit and discount policies are evaluated on a routine basis to identify patterns of activity amongst individuals or departments;
  • Purchases and receiving functions are separate from invoice processing, accounts payable and general ledger functions;
  • The employee payroll list is approved and signed off by the CEO of the Company;
  • Employees that have access to proprietary information have to sigh  non-disclosure agreements;
  • Ground Rules are in place to regulate the acceptance of employees of gifts, discounts or services offered by a supplier or customer;

AlphaScript will compile a monthly report in accordance with the areas of evaluation as per the medical scheme’s Fraud Framework to report on the detection of fraud both within the medical scheme’s business environment and in the external environment as soon as AlphaScript has a reasonable suspicion that such an incident has occurred.

To minimize the risk of fraud AlphaScript will develop Risk Identification Procedures as part of the Risk Management Program in accordance with the medical scheme’s fraud prevention charter during the initiation phase of a new medical scheme contract to prevent the following type of premeditated fraudulent activities:

Illegal Scripts:
A script that was not generated by a valid doctor, or the script does not comply with legal requirements, an eventuality that is not possible on the Alpha Script System since all the script processing is done centrally and it will be picked in the QA validation process

False Claiming:
This occurs when a claim is processed and approved but not dispensed, an eventuality that is not possible on the AlphaScript Pharmacy Management System since all the claim processing is cone centrally and it will be picked up through standardized exception reporting highlighting such irregularity;

False Orders:
This occurs when orders are generated for medication that is not dispensed, an eventuality that is not possible on the AlphaScript Pharmacy Management System since AlphaScript does all the ordering and it will be picked-up through standardized exception reporting highlighting such irregularity;

Incorrect pricing:
When incorrect prices are charged for medicines thereby infringing the SEP regulations and creating increased co-payments for patients, an eventuality that is not possible on the AlphaScript Pharmacy Management System since our master product/price file is imported from the master DoH SEP file and prices are hard coded in the back-end of the AlphaScript Pharmacy Management System and cannot be overriden by an end-user;

Invalid patients:
Patients that are no longer valid members of the medical scheme, an eventuality that will not possible on the AlphaScript Pharmacy Management System once the medical scheme master membership file has been uploaded into the AlphaScript Pharmacy Management System. This will also be picked up during the QA validation process depending on what member verification protocol the Medical Scheme wants AlphaScript to use ie, ID; Medical Aid Card and or Biometric scanning;

Patient fraud:
Patients claiming for non-members of the medical scheme, an eventuality that is not possible once the medical scheme master membership file has been uploaded into the AlphaScript Pharmacy Management System;

Patients and Providers committing premeditated fraud by falsifying claims in order to fund other services and or products instead of what was claimed, an eventuality that will not be possible due to the centralized script management, procurement and supply of claimed and approved medicine.

Incorrect Products:
Products dispensed that do not match the approved products, an eventuality that will not be possible due to Script and parcel QA validation processed explained herein;

The following stakeholders has a responsibility in the Fraud Prevention Program:

Patient:

  • The patient has a responsibility to check claims against his/her medical aid statements;
  • The patients must contact the call centre to follow-up on any suspicious claims and or transactions reflected on his/her end-of-the-month statement;
  • The above will also assist in preventing incorrect pricing of being used;
  • The patient also has the responsibility to check the dispensed products against the certified copy of the claim provided at the point of service delivery which effects the transfer of ownership to the patient once duly signed by the patient – this can help to prevent incorrect Products of being dispensed.

The AlphaScript Script and Parcel QA Pharmacist as well as the AlphaScript Network Provider:

  • The Pharmacist has the responsibility to check all scripts thoroughly as dictated in the GPP guidelines – this will help to prevent illegal scripts;
  • As the proposed solution relies on the personal relationship between the AlphaScript Network Provider and the patient, this provides an opportunity for the prevention of invalid patients. This happens in two ways:
  • Firstly the AlphaScript Network Provider has a personal relationship with the patients and will be aware of their status and their conditions;
  • The AlphaScript Network Provider will also require a patient to present proof of identification before dispensing medication;
  • This also prevents patient fraud.

Auditor:

  • An auditor will perform financial audits to validate the process, systematic and procedural flow of the transaction.
  • This helps in the prevention of:
    False Claims
    False Orders
    Incorrect Pricing;
    Incorrect Products

AlphaScript Pharmacy Management System:

The AlphaScript Pharmacy Management System has the following anti-fraud functionalities:

Price Updates:

  • By automating all price imports from the DoH master SEP file;
  • This reduces the risk of human error and or fraudulent intervention;

Audit Trail:
All changes, deletions, and transactions made are logged on the system, encrypted with the users Username and Password as well as date-time-stamped;

A record is held of:

  • Who modified the data;
  • When was it modified; and
  • What modifications were made to the data;

These AlphaScript Pharmacy Management System generated features prevent:

  • False Claiming: Stock-on-hand is electronically monitored;
  • False Orders: Orders are system generated with a unique tracking number that incorporates the original script template number that was also system generated when the script was originally loaded onto the patient profile;
  • Incorrect Pricing: Automated Price updates;
  • Invalid Patients: Integrity is reliant on cross mapping with medical scheme data;
  • Patient Fraud: Record of ID numbers to be used by Pharmacist for comparison with proof of ID as presented with the collection of the medicine;
  • Incorrect Products: Orders are system generated and stock levels are electronically computed and maintained based on stock movement.
2018-08-11T10:04:27+00:00