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 includes but is not limited to 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 recently launched its new 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 environment.


HFMU

International Links

PMBs were introduced into the Medical Schemes Act to ensure that members of medical schemes would not run out of benefits for certain conditions and find themselves forced to go to state hospitals for treatment. These PMBs cover a wide range of close to 300 conditions, such as meningitis, various cancers, menopausal management, cardiac treatment and many others including medical emergencies.

PMBs were introduced into the Medical Schemes Act to ensure that members of medical schemes would not run out of benefits for certain conditions and find themselves forced to go to state hospitals for treatment.

Summit Presentations :

PMBs were introduced into the Medical Schemes Act to ensure that members of medical schemes would not run out of benefits for certain conditions and find themselves forced to go to state hospitals for treatment. These PMBs cover a wide range of close to 300 conditions, such as meningitis, various cancers, menopausal management, cardiac treatment and many others including medical emergencies.

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)
  • 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.

HFMU Database

The HFMU has established a database which is the intellectual property of HFMU members. This database consists of three sections, all of which 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 HFMU database. The sections are namely:

Employee Section

This section 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.

Medical Scheme Member Section

This section 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.

HFMU Database Login [Members Only]

To login to the HFMU database, please click here.

Initiatives

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.

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