Poor collaboration at the right level, the lack of accountability and no proactive participation were identified as some of the stumbling blocks in the fight against malfeasance in the healthcare industry at the Fraud, Waste and Abuse Indaba.

The Board of Healthcare Funders of Southern Africa (BHF) held the Indaba from 14-15 November 2018 to mark International Fraud and Awareness Week.

BHF’s Managing Director, Dr Katlego Mothudi, said the Healthcare Forensic Management Unit (HFMU) has started collaborating with other fraud combating institutions. He believes there is a need for synergy between the healthcare sector, law enforcement agencies, the legal fraternity and prosecutorial agencies.

“The work that we do focuses on some of the elements on fighting fraud and money recoveries. We want also to extend that to successful prosecutions of the fraudsters. At the moment, there is a formalisation in the process of a relationship with the Special Investigations Unit (SIU). We have drafted a memorandum of understanding (MoU) which will be signed off in the next few weeks,” said Dr Mothudi.

He added that preventing fraud in the healthcare sector will make healthcare affordable and will also bring long-term benefits to the sector.

“Our expertise in the private sector on fighting fraud gathered over time, could help in making sure that we also protect the funds that will be deployed in the National Health Insurance (NHI) vehicle in collaboration with those resources that are currently in the state. So, it is a win-win situation,” said Dr Mothudi.

The Council of Medical Schemes (CMS) Senior Health Economist, Nondumiso Khumalo, said when looking at the impact and threats fraud poses to healthcare the industry needs to adopt a holistic picture that includes suppliers, manufacturers, providers and consumers.

“Impact is felt at a financial level when administrators incur costs. The quality of healthcare is affected because of the deviation of costs,” said Khumalo.

According to the CMS, in 2017 the proportion of claims attributed to fraud, waste and abuse amounted to R30.15 billion. From a global perspective, the exposure rate to corporate fraud has risen by 28% since 2007 from an industry average of 8%. In South Africa, estimates range from 3 to 15% of claims.

According to Khumalo, that as a cost driver in medical schemes, fraud contributes to the costs barrier to entry and has left the membership stagnated at 8.8 million lives.

The BHF runs the HFMU Online Portal, a healthcare information sharing tool designed to enhance the industry’s ability to curb incidents of fraud, waste and abuse. The portal is a contributory database which enables members to submit, track, monitor and share preventive and investigative information.

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