A mystery letter that spared benefits

The Scheme received a tipoff letter that saved both GEMS and its members an enormous amount in fraudulent claims. The letter provided the Scheme with sufficient information to openly conduct an investigation that eventually led to the sentencing of an Empangeni pharmacist.

So what exactly is the story? It is alleged that a teacher in the Empangeni region, in exchange for commission, was recruiting other teachers who are Members of GEMS and other undisclosed medical schemes to purchase products such as vitamin supplements and various other products from this particular pharmacy. The pharmacist would use false claim codes to cover up the benefit theft. According to the finding of a script audit conducted by GEMS for the period of December 2006 to May 2009, the pharmacist committed various other offenses such as duplicating claims, the use of incorrect dependant codes and incorrect membership numbers, just to mention a few.
During November 2008 the Scheme put the claims for this Empangeni pharmacy on hold, on suspicion that they were fraudulent. An investigation was conducted and this led to a conviction in favour of the Scheme. On 8 February 2013, the Magistrates Court sentenced the pharmacy owner to a R15, 000 fine or 18 months imprisonment and a further 18 months imprisonment which is wholly suspended on condition that the accused is not convicted of fraud, theft or attempted theft, during the period of suspension of five years.

GEMS always encourages members and the entire GEMS family to report any suspected fraudulent activity. We urge our members not to collude with service providers or help them steal their benefits and to steal from the Scheme. We are very happy with the conviction; the mystery letter saved the Scheme from criminal extortion and helped protect the benefits of our members.
Remember to protect what is yours! Always report any suspected fraudulent activities by calling the 24-hour toll-free GEMS Fraud Line on 0800 21 22 02. You can also send an email to [email protected] or send a fax to 086 726 1681. Information can also be posted to:
The Fraud Services Manager
PO Box 21076
Valhalla
0137