Participants can request that other users provide them with information. The request will be distributed to all HFMU participants, and members can provide feedback on the system in the tab where it states, "provide feedback on request".
This tab provides an opportunity for a participant to send a tip-off to all HFMU members notifying them of potential fraudulent activities, thus enabling members to mitigate any potential risks within their respective environments.
Participants can load cases which they have investigated and have confirmed that the perpetrator is guilty of fraud or misconduct. In the event where the matter has been taken further (e.g. saps case, hpcsa etc.), participants will be able to provide an update on the status of the case once the outcome has been received.
All investigation cases which have been uploaded by members will be available on this tab for members to view.
The purpose of this app is to demonstrate the power of participants working together. For this we'll look at something that is very difficult to analyse with one scheme's data only, number of consultations per day for each provider.
The idea is to get all visits to providers and group it together over multiple schemes.
The fields required are as follows:
Practice number: Character (seven digit code, ex 1234567)
Service date: Date (use universal format of "yyyy-mm-dd", only 2018 dates for initial upload)
Member number: Character
Dependent code: Character
Below is an example sql query to extract the data:select distinct p.discpdescr, p.prnumber, c.servicedate, c.membernumber, c.dependentcode
This data must be stored in a CSV file and uploaded to this app.
This data is linked to your scheme, but it is encrypted and not available to any other users.The filename must contain your schemecode, an underscore and the word "exposure", thus your filename should be:
The ftp details are the same for each scheme, users only have write rights and can thus not access or view each others data.
The details are as follows:Server: www.bhfportal.co.za
The utiliastion module investigates the number of events, where an event is a distinct service date for a unique beneficiary at a specific provider.
The first area of investigation is simply the number of events or consultations per provider, usualy per day. This can be used to identify providers with a too high count, and to view provider claiming trends
Next is a clustering model that creates a network of provider or disciplines that are often visited together, or within a short time frame of each other.
The above models will all greatly improve with more data, eg diagnosis and tariff codes or external data like wellness and disease management information.
The content of this report has been compiled from information supplied to us by our participating members of the Health Fraud Management Unit (HFMU) and could include information derived from interviews with internal and external parties, the perusal of documentary and other evidence, analysis of electronic data extracted from electronic equipment in the form of spread sheets mails and records which became available during the course of the investigation by virtue of prevailing legislative prescripts.
This report is to be used solely for the purpose and subject to the limitations as set out in this section. The report serves as an information document and may not be used for any other purpose without the required written consent of the HFMU.
In respect of the review of the documentation made available to us, we have not verified the authenticity, credibility or validity of such documentation.
The documentation used in the report was supplied to us via our portal by our participating members.
HFMU cannot be held responsible for any information that was withheld, concealed or misrepresented to us.
We are not participating in the management of our participating members in any way and to the best of our knowledge, would not be acting in conflict of interest.
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We do not accept any liability for any loss, either directly or indirectly, suffered by yourselves or any other party arising from our due and proper fulfilment of this mandate. We confirm that you indemnify us in respect of any claim or legal costs which may arise in this regard, but this indemnity does not apply to anything done by us unlawfully.
Should it come to our attention that any facts or information supplied to us by our participating members, which were known to be incorrect, we will be entitled to terminate this mandate.
The contents of this report and/or communications relating to this assignment are confidential. No part thereof may be provided to other parties, quoted, referred to or disclosed in whole or in part by any other party, or be used for any other purpose, without HFMU prior written consent.
This report does not constitute an audit in terms of Generally Accepted Audit Practice, or any other control attestation from an audit perspective, but constitutes an investigation that was conducted by our participating members of potential irregularities and current system weaknesses, in terms of which we may not be able to provide a full set of control failures.
We do not express any opinions on the interpretation of the law or the legal effect of the facts on the guilt or innocence of any person/s. The procedures we performed do not constitute an audit or a review in accordance with International Standards on Auditing or International Standards on Review Engagements (or relevant national standards or practices). Consequently, we do not express any audit assurance.
We are not a legal practice and as such, do not provide any legal advice with this report.
All observations made in this report are based on the assumption that the information provided to us is authentic, valid, correct and complete, but we cannot guarantee the authenticity, validity, correctness and completeness thereof.
We have included information obtained from our participating members via our HFMU portal. Unless expressly indicated otherwise, we cannot verify that information so obtained as credible or truthful. The aforementioned evidence was deemed appropriate to provide a perspective of the evidence obtained.
Note that the data analysis in this report were based on information received from our participating members.
All observations and recommendations made in this report are based on the assumption that the information provided to us is correct and accurate.
We were not in a position to test nor have we verified the completeness, validity, or authenticity of the documentation and information provided to us.
We have not verified the completeness, validity, or authenticity of the information extracted from websites on the Internet. We further assume no responsibility for the accuracy of the information obtained from online sources, nor do we guarantee that we have located all relevant information that might exist regarding a certain subject.
Although we endeavour to be as comprehensive as possible in gathering information, we may not be in a position to test the accuracy or completeness of information obtained from outside sources. In addition, although the information gathered from public record sources are generally accepted to be accurate, we cannot guarantee its veracity; in particular, we cannot monitor the speed with which data providers update their records and thus such information is only correct as far as we are aware.
This report has been compiled solely to provide you with our findings in respect of the independent investigation we conducted in terms of our mandate. Annexures on which our findings were based have been attached and should be read in conjunction with this report. HFMU therefore assumes no responsibility to any user of this report other than you. Any other persons who choose to rely on our report do so entirely at their own risk.
Conclusions and recommendations are subject to the receipt of appropriate supporting evidence and/or information.
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