HFMU INVESTIGATOR TRAINING INDABA OPENING AND WELCOME

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1 HFMU INVESTIGATOR TRAINING INDABA OPENING AND WELCOME Esteemed speakers, colleagues and guests it is with great pleasure that we welcome you to the 2013 HFMU investigator training indaba. We trust that you will find the speaker presentations at this 2 day indaba informative and useful in your daily fight against white collar crime. The aim of this training indaba is to hopefully equip you better in your pursuit of justice and ethical behaviour in healthcare. Please allow me to elaborate a little on the background and growth of the HFMU. The HFMU is a division of the Board of Healthcare Funders of Southern Africa and was established in At the time, the main purpose of the HFMU was to share information on unethical activities against the benefits of medical schemes in order to curb incidents of such activities. Henry Ford once said: Coming together is a beginning Keeping together is progress Working together is success You can t build a reputation on what you are GOING to do! The HFMU has illustrated that Henry Ford was a wise man and the unit strives to maintain and build on its reputation. The unit has evolved, in that it now shares information with some of the life houses, management groups and other insurers. There is strong evidence that the same perpetrators of fraudulent activities in the healthcare space are also active in the insurance space where hospital cash plans are in place. There was also an apparent need to bridge the gap which existed between different silos in healthcare. We continue to build those bridges. 1 P age - HFMU Investigator Training Indaba 2013

2 In our fight against white collar crime, the HFMU hopes to close the net by means of close collaboration with the authorities such as the NPA, SAPS, AFU and Organised Crime units and also with the various statutory bodies. We joined hands with our international counterparts in 2011 and since signing the Memorandum of Understanding, we are now officially recognised partners of the Global Health Care Anti fraud Network (GHCAN). The GHCAN comprises of the Canadian Health Care Anti fraud Association, the National Health Care Fraud Association (USA), the European Healthcare Fraud and Corruption Network, the Health Insurance Counter Fraud Group (UK) and the HFMU. The main benefit of this partnership is sharing of information regarding fraud prevention, modus operandi and training material. The HFMU is about to embark on a fraud resilience survey with the assistance of the Head of Counter Fraud Services at PKF in the UK and the University of Portsmouth. The first step of this survey would enable us to evaluate our own strengths and weaknesses and this will then lead up to our own healthcare fraud survey. We are hopeful that this initiative will place us in a better position to establish the true cost of white collar crime in the healthcare arena. This training indaba forms part of the HFMU s focus on training, education and awareness. Other initiatives are: The Healthcare Interest Group under the banner of the ACFESA where we will develop healthcare specific training modules which will eventually lead to SAQWA (SA Qualifications Authority) accreditation for healthcare investigators; BHF Trustee training presentations; A LinkedIn group sharing of news and networking; Membership outreach Operational meetings throughout the year 2 P age - HFMU Investigator Training Indaba 2013

3 HFMU policies and procedures are firmly entrenched and participants enter into a strict Code of Conduct. I mention this because, after 9 years, we still receive resistance from certain quarters. The unit does not aim to negate the powers of the authorities and regulators. It does however request that those in power respect an HFMU participant s fiduciary duty to protect its member s funds and to recognise its determination to stand together with all stakeholders in its efforts to stamp out some of the crime which affects the economy. Moving into an NHI environment it would make sense for the entire healthcare industry to stand united rather than be at odds. I would like to share some fraud facts with you... Fraud and corruption occur whether systems are predominantly public or private, well funded or poorly funded and technically simple or sophisticated. No country is exempt. Fraud affects every kind of healthcare system. Fraud and corruption activities can take place in any area of healthcare delivery. Motives of fraudsters are universal. The following processes stand out as having high inherent risk of corruption: 1. Provision of services by medical personnel; 2. Human resources management; 3. Drug selection and use; 4. Procurement of drugs and medical equipment; 5. Distribution and storage of drugs; 6. Regulatory systems; 7. Fee for service models. The forging of a doctor s signature on a prescription and the theft of basic medical equipment may seem trivial but, when added up, accounts for billions of rand lost every year money that could have been spent on patient care. The sooner we treat fraud as a cost like any other, to be measured and minimized, the quicker more money will be available for better patient care. 3 P age - HFMU Investigator Training Indaba 2013

4 Jim Gee, director of Counter Fraud Services at PKF in the United Kingdom of Great Britain and Northern Ireland, calls healthcare fraud the last unreduced healthcare cost. Until there is recognition of the extent of the problem, steps cannot be taken to remedy it. It is conservatively estimated that approximately 53 billion Euros are spent annually on fraud, error and wastage. When it comes to tackling healthcare fraud head on, tough sentencing is not enough. The crime has been committed, the money is gone we need to focus more on prevention. There is a general perception amongst many that fraud is a victimless crime. At its most devastating, fraud can destroy an organisation. Fraud very often leads to more fraud. If a culture begins to emerge where such behaviour is tolerated or dealt with too lightly, it is more likely to lead to more fraud. Therefore if an organisation is suffering from fraud or not dealing with fraud effectively as it may perceive it as too insignificant to warrant action, this can send out a message that fraud is acceptable. Some will also see others getting away with it and think it s only fair for them to do so as well. The impact of fraud, if not effectively tackled, can therefore lead to more fraud. That is why it s vital to pursue zero tolerance. Fraudsters will actively seek out opportunities to commit fraud. Therefore reducing the opportunities to commit fraud is very important. International experts say that to successfully reduce the cost of fraud requires more than just reacting to individual incidents after losses have been incurred. It requires work to strengthen anti fraud cultures, to take measures to deter fraud and to remove systemic weaknesses that provide opportunities for fraudulent behaviour. Research has shown over the years that you can never completely eradicate the dishonest minority but, by developing a strong anti fraud culture and strong peergroup pressure, you can maximize the size of the honest majority. 4 P age - HFMU Investigator Training Indaba 2013

5 The large amounts of money involved in the healthcare sector and the complexities of many healthcare systems makes the healthcare sector particularly vulnerable to corruption. In most countries healthcare providers have assumed a cultural role as trusted healers who are above suspicion. We don t like to believe that healthcare providers could have conflicts of interest that affect their judgement, but in fact this can be the case. In an era of tighter budgets and more competitive markets, organisations are looking for innovative ways to reduce costs and increase profits. Much is made of their potential to achieve what is often described as competitive advantage. We are saying that fraud affects everyone in any line of business and if we do not stand united in the fight against white collar crime, we will all continue to bleed at the mercy of unscrupulous behaviour. Hence the HFMU strap line A unified approach to the reduction of crime in healthcare. Central to any counter fraud strategy is the need for counter fraud professionals to be appropriately trained, educated and informed in the latest research, methodologies and thinking relating to fraud. It can also mean attending conferences, seminars and training indabas such as this one, as well as reading professional magazines and journals. It is important that these avenues are pursued on a regular basis. Underpinning this is the need where there is evidence to pursue evidence based solutions to the problems facing organisations. Ladies and gentleman, we are confident that each of you will find something in our programme to take away with you and apply to your day to day activities. Please feel free to interact with our highly skilled speakers and we trust that you will find ample networking opportunities over the next 2 days. THANKS I would like to thank the following sponsors of this event: Bonitas Medical Fund our main sponsor and without whom this event would not have been possible. Verirad Health Funder Risk Managers Qhubeka Forensic Services 5 P age - HFMU Investigator Training Indaba 2013