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Fraud, Waste & Abuse Management
- Established in 2023, AFA provides Botswana’s first Healthcare Fraud, Waste, and Abuse (FWA) service. Our FWA service protects members and reduces unnecessary costs by identifying and preventing fraudulent claims, overuse of healthcare services, and misuse of resources. Through advanced data analytics, audits, and collaboration with healthcare providers, we proactively monitor and address suspicious activities. This service ensures responsible use of healthcare dollars, promoting a trustworthy and efficient healthcare system for all members.
- Key Features:
- Advanced Data Analytics: Using predictive algorithms and machine learning to detect unusual patterns and potential fraudulent activities in real-time and retrospectively.
- Claims Auditing and Monitoring: Conducting regular audits and monitoring claims for inconsistencies, duplicate billing, and overuse of services.
- Provider and Member Education: Offering resources and training to educate providers and members on FWA policies and best practices to prevent accidental misuse.
- Collaboration with Law Enforcement: AFA works with regulatory bodies and law enforcement agencies to investigate and address confirmed cases of fraud. AFA currently has several cases of FWA reported to local authorities.
- Case Management and Resolution: AFA has a dedicated team of clinical forensic analysts to manage investigations, resolve issues, and recover funds from confirmed fraudulent or wasteful activities.
- Proactive Prevention Programs: We have implemented preventive strategies, such as pre-payment reviews and verification checks, to reduce opportunities for FWA before claims are processed.