About HFMU

The Healthcare Forensic Management Unit (HFMU) is an information and resource sharing group which enjoys the participation of the majority of medical schemes, administrators, management and administration entities and some insurers.

The core focus of this unit is to facilitate a unified approach with regards to fraud in the medical schemes environment. This is achieved by sharing information regarding fraud, over billing and over servicing in order to minimise fraud across the industry and to protect medical schemes from healthcare providers and medical scheme members who shift their wrongdoings from one medical scheme to another once “caught out”.

The HFMU is co-ordinated and administrated under the auspices of The Board of Healthcare Funders of Southern Africa and is unique in that it is the only initiative of its kind within the healthcare industry.

The benefits of participating in the HFMU are not limited to but include working within a strict legal framework to ensure a fair and transparent approach; no duplication of efforts; collaboration with professional and international bodies; a more streamlined process with criminal matters due to newly formed relationships with the likes of the SAPS, NPA and the various prosecuting authorities; regular training workshops and much more.

The unit also recently launched its new name and logo and can proudly say that the Healthcare Forensic Management Unit is here to stay and we will continue to maintain a zero tolerance approach around fraudulent activities within the healthcare enviroment.

- Lynette Swanepoel, Manager: HFMU

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HFMU Criteria and Databases

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 HFMU compiled a series of 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 HFMU now represents some 95% of the industry, including active participation from both the funding and provider sectors.

It also enjoys the collaboration, participation and support of management groups and professional bodies in the medical industry including:

• South African Medical Association (SAMA)
• South African Dental Association (SADA)
• South African Pharmacy Council
• Council for Medical Schemes (CMS)
• Health Professions Council (HPCSA)
• South African Optometric Association (SAOA)
• Healthman
• Spesnet

Six weekly working group meetings are held where information is shared and current issues discussed. Information sharing has eliminated duplication of work and enabled HFMU 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 HFMU has established four databases, which are the intellectual property of HFMU 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 loaded on to the databases.

1. 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.

2. 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.

3. 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 HFMU has already saved the healthcare industry hundreds of millions of rands.

4. Medical Scheme Membership database
This database consists 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:

obviate the need for membership certificates

provide significant benefits for new business departments.

be an invaluable tool in establishing whether any individual has dual membership of medical schemes which is currently illegal.

allow access to information through the member's ID number and only information relating to that specific member and their dependents will be displayed.

5. Provider profiling database
All claims and consultation information across the industry will be recorded on this database. The HFMU 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.

HFMU Feedback Form

Contact BHF's FMU department for Tip-offs, Comments and or Suggestions.

The contents of this correspondence will be kept confidential.

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HFMU Meetings

13th Trennial World Congress on Public Health 2012- Addis Ababa, Ethiopia

→ Click here for more details

EHFCN Annual Conference 2011 - Krakow, Poland

EHFCN Annual Conference 2011 - Krakow, Poland - Presentations → click here to download

HFMU Breakfast Meeting - 14 June 2011

Breakfast Meeting Presentations - 14 June 2011 → click here to download

Investigator Indaba - 1 & 2 November 2010

HFMU Investigator Indaba - 1 & 2 November 2010 Presentations → click here to download

Click here to join our Group. Members only.

HFMU Participating Members

The HFMU has established four databases, which are the intellectual property of HFMU 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 loaded on to the databases.

To read more on these databases, please click here

Please click here to download the Memorandum of Understanding.

The following bodies have pledged support for the initiative.

• Council for Medical Schemes (CMS)
• Health Professions Council of South Africa (HPCSA)
• South African Medical Association (SAMA)

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Click on the relevant links below to view HFMU members.

Policies and Procedures

Please refer to the Policies and Procedures document which will provide clarity and further information with regard to the HFMU division.

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.

For more details on the HFMU Policies and Procedures please click here

Costs

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

For the more information on costs related to HFMU participation, please contact Chelesile Mtshiya on chelesilem@bhfglobal.com or call 0115370200.

Confidentiality

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

With a view to streamlining the collaborative process and finding ways to improve on the success on cases lodged with the SAPS the HFMU has entered into discussions with the National Prosecution Authority (NPA) and the Units for Serious Economic Offences and Commercial Crime.