Please refer to the Policies and Procedures document which will provide clarity and further information with regard to our FMU department

• Allcare Administrators (Pty) Ltd.
• De Beers Benefit Society
• Dental Information Systems (DENIS)
• Discovery Health
• Eternity Private Health
• Full Circle Health
• Global Health
• Medicover Investments Ltd
• Medihelp
• Medisense
• Metropolitan Health Group
• Momentum Health
• Multimed
• Naspers
• Old Mutual Healthcare
• Opmed
• Polmed
• Preferred Provider Negotiators (PPN)
• Private Health Administrators
• Professional Provident Society (PPS)
• Prosperity Health
• Pro Sano
• Resolution Health
• SAMWUMED
• Sizwe Medical Fund
• Sovereign Health
• Spectramed
• Status Medical Aid Administrators Ltd.
• Telemed

And the following bodies have pledged support for the initiative and are represented on the Task Team.

• Council for Medical Schemes
• Health Professions Council
• South African Medical Association

Background

The healthcare sector is defrauded of between R4 and R8 billion every year. This increases costs for all stakeholders, from funders and providers to medical scheme members.

Administrators, funders and medical schemes were achieving little in acting individually against perpetrators and were duplicating work, and thereby wasting available and limited resources. While some larger schemes had forensic units to conduct investigations, smaller schemes were unable to do this because of the budget required.

The environment was conducive to fraud, with no visible policing in place, a weak legal system and relatively ineffective governing bodies. Furthermore, the mindset of many members of medical schemes promoted fraud in that they saw contributions as a grudge purchase and sought opportunities to gain advantage at the expense of schemes. Many providers also abused the system to increase their profits. Other organisations further undermined the poor moral/ethical approach with perverse incentives.

Convened by the Board of Healthcare Funders, stakeholders in the healthcare sector identified the need for a united, focused and cohesive industry body to combat fraud, focusing on prevention and on changing patterns of behaviour. Thus the Forensic Management Unit (FMU) was established in 2003.

Criteria

Stakeholders acknowledged that fraud, and information relating to it, could not be considered a competitive issue and acknowledged that a collective approach was necessary to achieve success.

They identified a need to change patterns of behaviour, preferring prevention to investigation. Simply recouping funds was not a solution. Real disincentives had to be created to discourage fraud and to promote rehabilitation. To achieve these goals, full participation across the industry was a requisite.

To ensure that the constitutional rights of all individuals were respected and safeguarded, the FMU compiled a series of collective protocols operating within an accepted legal framework to investigate, assess and punish fraud. A common language was put in place to facilitate discussion and decision-making. The FMU now represents some 95% of the industry, including active participation from both the funding and provider sectors.

It also enjoys the participation and support of professional bodies in the medical industry including

• South African Medical Association (SAMA)
• South African Dental Association (SADA)
• Pharmaceutical bodies
• Council for Medical Schemes (CMS)
• Health Professions Council (HPCSA)
• South African Optometric Association (SAOA)

Six weekly working group meetings are held where information is shared and current issues discussed. Information sharing has eliminated duplication of work and enabled FMU members to act collectively against perpetrators. Previously, operating in isolation, all they generally achieved was to encourage perpetrators to move their fraudulent behaviour to other schemes, which were unaware of their criminal activities.

Progress to date

The FMU has established three databases, which are the intellectual property of FMU members and are managed by TransUnion Credit Bureau. They are accessible to participating members on a 24/7 basis. As information is collated from medical schemes, administrators and forensic organisations, it is immediately loaded on to the databases.

Employee database
This lists employees of medical schemes and administrators who have acted fraudulently or unethically. It enables the industry to protect itself from re-employing such dishonest individuals and to improve its own recruitment practices.

Service provider database
This identifies and lists service providers found guilty and being investigated for fraud. At a glance all participating schemes are able to view those healthcare practitioners who have either been found to be acting fraudulently or who are under investigation. Medical schemes are thus able to select service providers more accurately and improve their own audit and investigative procedures. The database also serves as a deterrent for those providers tempted to indulge in fraudulent behaviour. Six provider disciplines have been listed including pharmacists, pathologists, GPs, dentists, optometrists and radiologists.

Medical scheme member database
This lists all medical scheme members who have been found guilty of acting fraudulently or who are under investigation. It will enable medical schemes and administrators to share information about such members, promoting better management of members and their claims.

It has been widely acknowledged by participating members that benefits to the industry are already evident and are on the increase. The FMU has already saved the healthcare industry hundreds of millions of rands.

Investigation protocol

In order to ensure a fair and transparent process, input into investigative processes was sought from statutory bodies and professional associations.
The FMU's investigative protocols give guidelines to participating schemes on the manner in which investigations should be conducted, the steps to be taken following an investigation and the reaching of settlements. Because of the migration of skills from the country, much emphasis is placed on rehabilitation of healthcare practitioners

Industry co-ordinator

Ms Lynette Swanepoel has been employed as our industry FMU co-ordinator since September 2005 and is responsible primarily for co-ordinating the industry investigations which are taking place. She also provides forensic expertise to participating organisations.

Currently in progress

Medical Scheme Membership database
This database will consist of information on all medical scheme members and their dependents. Apart from providing information on the history of all members and their dependents at a glance, it will also:

Provider profiling database
All claims and consultation information across the industry will be recorded on this database. The FMU and relevant departments within medical schemes or administrator organisations will be able to determine the industry norm in terms of claims or consultations for a specific provider. This will enable them to determine excessive claims as well as industry costs and claims profiles. It will also pave the way for benchmarks to be established where procedures are concerned.

Having access to all these databases is extremely advantageous to schemes for research and development, to combat fraud and dishonest behaviour, to identify those guilty of fraud, to help bring costs down, to benefit from the resources of the whole industry in identifying and preventing fraud and establish new patterns of behaviour through prevention and rehabilitation.

Legislation

Meetings have been held with the Attorney General to lobby government for specific healthcare fraud legislation with dedicated prosecutors and courts where there is a thorough understanding of the medical healthcare industry.

Knowledge database
A registry is currently being developed which will list special skills within the healthcare forensics arena, e.g. coding specialists, handwriting specialists, etc. so that participating organisations further pool knowledge.

Costs

Currently the only costs involved in FMU participation are the fees payable to TransUnion Credit Bureau for utilisation of the Medical Schemes Forensic Database (MSFD)

Confidentiality

In order to ensure confidentiality, all participating members sign a code of conduct with the TransUnion subscriber agreement as well as an agreement of participation.