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:

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.