Healthcare Forensic Advisory Services

Cross-discipline solutions to combat complex, real-world challenges for healthcare institutions

The healthcare industry is increasingly being plagued by instances of fraud, waste and abuse. A robust and decisive response to these issues is key to providing clarity and confidence to the market and unlocking the value that is lost to these undesirable practices.

The healthcare industry finds itself beset by attacks from every angle. Not only does it have to fend off external syndicates operating in this space; internally, too, it is prey to irregularities committed by its employees. All of this is overlaid by ever-increasing levels of regulatory scrutiny and governance requirements. If (or rather when) an issue arises that poses regulatory, financial or reputational risks, you, your stakeholders and the Regulators will require the reassurance of an effective response.

PwC Healthcare Forensic Advisory Services boasts a global team of skilled professionals that are equipped and experienced in addressing your every need across the entire spectrum – from investigating fraud, waste and abuse in a thorough and independent manner to addressing cyber-attacks; and from managing your healthcare governance challenges to providing sound advice on how to address fraud risks in your environment.


Our services to you include:

Forensic Investigations

Through a network of seasoned professionals with expertise in technical accounting, forensic analysis and fraud examination, we bring a wealth of knowledge, experience and techniques to help you respond to allegations and regulatory investigations with fact-finding that can withstand third-party scrutiny. We provide:

• Forensic accounting and financial investigations expertise

• Global presence in 158 countries

• Global Intelligence Centre of Excellence

• Experience with global regulatory environments



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Disputes, Claims & Controversies

We help organisations across the globe address the complex issues of fraud, corruption or corporate abuse. We assess economic damages in connection with regulatory matters, commercial litigation and business interruption, including:

• Quantification of damages

• Statistical theory and applications

• Expert witness testimony

• Service as arbitrators, mediators and special masters

• Technical accounting, valuation and business analytics skills


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PwC’s forensic technologists across the globe have experience helping our clients respond to 1 000, cybersecurity projects. Our cyber breach teams will help you rapidly respond to, investigate and remediate cyber incidents, combining technical skills and business strategies to protect your brand value.

Together, we will:

• Identify the source, location and nature of breaches with our breach indicator assessment tool

• Quantify and mitigate associated losses

• Assess the business risk and customer impact

• Remediate vulnerabilities to minimize future occurrences



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Computer Forensics

Our teams have access to leading-edge forensic labs in 30 global locations, relational database software and proprietary tools to analysetransactional data-sets in innovative new ways. We will coordinate with your IT resource to provide thorough and swift access to facts and insights.

We offer:

• Data identification, preservation, collection, clustering, processing and analysis

• Familiarity with data privacy and protection rules

• Collection, recovery, filtering, processing and host review applications for fast-paced governmental investigations

• Keyword formulation, data filtering and review strategies, and

• Cybercrime awareness training aimed at the C-suite through a customised Healthcare module of our bespoke “Game of Threats” platform.


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Healthcare Governance

The Healthcare industry is undergoing significant changes, such as the amalgamation of medical schemes and an increased focus on good governance by the Regulator and other stakeholders. The members of medical schemes are becoming more aware of, and are taking a more active interest in, elections to the Board of Trustees (the Boards), annual general meetings (AGMs) and special general meetings (SGMs).

More stringent requirements regarding the appointment of fit and proper individuals to the Boards of Trustees have furthermore resulted in the Council for Medical Schemes requiring that there should be some form of independent oversight during the election of members to the Boards of Trustees.

PwC Healthcare Forensic Advisory Services can assist with all of these governance challenges. From the board room, electoral conferences, AGMs and SGMs right through to the court–room, we support medical schemes, with the management and overseeing of AGMs and SGMs as well as electoral conferences for the election of members to the Boards of Trustees of medical schemes.

Electoral support

With the ever-increasing requirements for robust due diligence to be incorporated into medical scheme electoral processes, we provide unique, innovative, custom-built solutions for clients, whether they require manual running of elections, automated online solutions or a combination of these platforms.

Our solutions provide added security, independent oversight and can stand the test of regulatory scrutiny.

We assist our clients with management and oversight over the:

• Nomination of candidates

• Proxy appointment process

• Vetting of nominees in terms of Scheme Rules, using our innovative corporate intelligence services and

• Post-voting activities.

We bring an innovative approach to elections that allows the client the options of running online and/or manual elections.

AGM and SGM support

Our AGM and SGM support includes overseeing the following:

• Set-up of AGM and SGM logistical arrangements

• Registration and validation of members in good standing on the day of the AGM and SGM

• Counting of motion votes during the AGM.

We further assist our healthcare clients, in liaison with the regulators, to ensure compliance with the Scheme Rules.


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Fraud prevention

Taking action to assist in preventing fraud, waste and abuse, will save your organisation from huge financial and reputational damage.

A pre-emptive review and the application of governance and controls will identify risks, develop efficiencies, provide a clear understanding of your position, or avoid future crises. On-going testing of existing controls helps to maintain compliance.

We provide ongoing testing of existing controls to help maintain compliance within your organisation. Amongst other service offerings:

• Fraud Risk Assessments

• Ethics Culture Survey

• Fraud HealthCheQ to benchmark risk managementpractices of organisations

• Development, review and updating of Fraud Prevention Policies and guiding documents, and

• Fraud and Ethics Awareness training



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Fraud Detection

We assist clients with Fraud Detection techniques which should be established to uncover fraud events when preventative measures fail or mitigated risks are realised.

Amongst other service offerings:

• Fraud detection reviews;

• Forensic Technology Solutions, including Data analytics, to analyse trends and uncover red flags



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Forensic Capacity Building

Through our forensic capacity building service, we assist clients to develop and build a prompt, competent, confidential investigation and resolution capacity.

This includes ensuring that appropriate people, processes, technology and governance are in place for an in-sourced, outsourced or partially outsourced forensic capacity for your organisation.

Amongst other service offerings:

• Developing, review and updating of forensic investigation methodologies

• Training on conducting forensic investigations, and

• Forensic capacity building



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Providing clarity and confidence

Our team of trained investigators comprises forensic accountants; fraud risk specialists; lawyers; regulatory investigators; and cyber, forensic technology and corporate intelligence experts. They will add value to your organisation by applying an approach that includes both proactive and reactive responses to the risks you face and challenges you may encounter. Their wealth of knowledge and experience can be brought to bear seamlessly on any assignment. We work closely with you, bringing immediate attention and providing regular updates on progress.Our aim is for you to feel in control of the scope and direction of the work.


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