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Section 59 Investigation. Board of Healthcare Funder and the Health Forensic Management Unit 30 July 2019. Fraud Waste Abuse. Overview. Who is BHF? Representative not for profit organisation. Platform for member engagement. Represents member interests. Develops industry standards.
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Section 59 Investigation Board of Healthcare Funder and the Health Forensic Management Unit 30 July 2019 Fraud Waste Abuse
Who is BHF? Representative not for profit organisation Platform for member engagement Represents member interests Develops industry standards Facilitates education and training • Promoting unity and collaboration • Member networking opportunities • Creating and developing relationships with key stakeholders • Lobbying and advocacy • Regulatory compliance • Legal review and policy development • Trends analysis • Protects image of industry • Thought leadership on industry issues • Enhancing member skill and knowledge • Member guidance • Tracking industry issues • Promoting stakeholder and consumer awareness • Best practice • Healthcare quality • Identify and recognise key industry stakeholders Provides and identifies opportunities Transformation through development • Profiling members and the healthcare industry • Identification of transformation opportunities in industry • Development of graduate programmes Source: BHF Strategy, 2017-2019
Why is the BHF concerned with fraud, waste and abuse (FWA)? • Bona fide payment without entitlement • Loss sustained by medical scheme due to theft, fraud, negligence or misconduct • Healthcare service providers leveraging lack of data visibility • Fighting FWA does not create competitive advantage • BHF as a central independent data repository
Business of a medical scheme • In return for a premium/contribution • Undertaking liability associated with: • Providing for obtaining a relevant health service • Granting assistance to defray expenditure incurred in connection with rendering of any relevant health service • Rendering a relevant health service by the medical scheme itself or in terms of an agreement reached with HSP’s
FWA Definitions Intent to deceive
FWA Examples Intent to deceive
FWA Strategies Legal and Governance framework COLLABORATION Joint action Information Sharing Data Sharing
Yesterday Submissions: Coding These provide more details of time spent. They are also an indicator of level of tariff These codes must tally
Yesterday Submissions: Schemes and Administrators not passing on savings to beneficiaries • This statement is not true in all contexts • There are some schemes that have demonstrated that they can reduce the amount of unnecessary utilisation (Waste). • These could increase reserves and pass on lower than average contribution increases. • Strategies employed include: • Use of nominated GPs • Use of effective contracting methods • Provision of more preventative care benefits
Global Perspective • The European Healthcare Fraud and Corruption Declaration of 2004 • Organizations from 28 countries, • Development of a European common standard of risk measurement, with annual statistically valid follow up exercises to measure progress in reducing losses to fraud and corruption throughout the EU.” • Improper Payments Information Act of 2002 (USA) • Public agencies should publish a “statistically valid estimate” of the extent of fraud and error in their programmes and activities. • Reinforced by the Improper Payments Elimination and Recovery Act of 2010. • Most major US public sector agencies have been measuring and reporting losses for more than a decade
Global Perspective • The financial cost of fraud and error can be accurately measured in the same way as other business costs. • Fraud accounts for losses of more than 3% of expenditure, with the 19 year average running at 5.85% and this figure has risen by 28% since 2007 • Fraud is the last great unreduced business cost, and its significant • Based on evidence, losses in ANY organization in ANY area of expenditure • At least 3% • Probably near 6% • Possibly more than 10%
Impact of FWA – Global View • USA - Healthcare costs (2011): About US$2.27 trillion, with 4 billion healthcare claims processed • USA National Health Care Anti-Fraud Association (NHCAA) estimated tens of billion dollarsfinancial losses due to fraud (2011) • USA Jan 2018: Four (4) Texas men accused of US$150m fraud: phony Medicare billing and money laundering • Global Health Care Anti-Fraud Network (GHCAN) estimates about US$ 260 billion or 6% of global health care spend is lost to fraud each year (Equivalent to Finland's or Malaysia’s GDP) • GHCAN Nov 2017: Fraud costs the NHS in England ₤1 billion a year • The Journal of the American Medical Association (JAMA) “estimates that abuse of prescription medicines world wide will soon outpace that of illicit drugs” • SADC - ?
HFMU within the context of the BHF governance structure Board Managing Director • Advisory, not a committee of the Board in respect of FWA: • Safeguarding of data • Operations of adequate systems, databases and controls • Reports to the MD • Recommendations Finance & Audit Committee Governance Committee Universal Healthcare Committee SADC Committee Human Capital Committee HFMU Steering Committee • Oversight provided by Governance Committee HFMU Operational Committee • Code of Conduct • Participation Agreement Members Non-Members
HFMU Legal Opinions • The HFMU considered legality on the intended activities. • Arears of potential concern included: • Competition Law • Protection of personal information • There are legal opinions on these matters that have been provided
HFMU Portal User Agreement & NDA • Participation agreement • guidelines on information sharing • Members may not act solely on the information received • Members to investigate individually • NDA between BHF and Participants • Data protection and confidentiality • assurance to data use
HFMU: Phase 2 More proactive rather than reactive Enhances phase 1 There is some data sharing required
HFMU: Data sharing for Phase 2 • 4 columns of data – service date, practice number, unique member identifier & dependent code * We recommend that the member identifier be encrypted
HFMU: Data sharing for Phase 2 • Your scheme’s claims are compared to rest of industry to identify potential fraud Industry View Single scheme view
HFMU: Data sharing for Phase 2 • Understanding the link with between providers (probably defrauding the scheme)
HFMU: Reports • Monthly reports to assist with investigations
