The document discusses healthcare fraud in Belgium, highlighting the increasing awareness and strategic efforts to combat it through a robust and integrated approach. It outlines various types of fraud, the roles of sickness funds and the National Institute for Health and Disability Insurance (NIHDI), and emphasizes the need for prevention, investigation, and enforcement measures. Additionally, it presents the importance of international cooperation and data availability to address inappropriate and low-value care in healthcare systems.

1. Jo De Cock - CEO NIHDI
04-02-2016 - OECD Paris
OECD Joint Network of
Senior Budget and Health
Officials:
The Belgian Experience

2. HEALTH CARE FRAUD:
NOT A NEW PROBLEM
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HEALTH CARE FRAUD:
BUT MORE AND MORE AWARENESS
Many findings of wasteful use of
resources have been reported in the
empirical literature, inter alia:
i) sub-optimal setups for delivery of
care;
ii) inefficient provision of acute
hospital care;
iii) fraud and corruption in health care
systems;
iv) a sub-optimal mix of preventative
versus curative care

4. HEALTH CARE FRAUD:
BUT MORE AND MORE AWARENESS
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5. HEALTH CARE FRAUD:
BUT MORE AND MORE AWARENESS
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6. SUSTAINABILITY OF HEALTH CARE
SYSTEMS: WHAT’S THE RIGHT WAY ?
• Investing less resources ?
• Developing additional funding mechanisms ?
• Reducing waste, increasing value ?
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7. WASTE
“ Waste is any activity in a process that consumes
resources without adding value ”
- Taiichi Ohno, Toyota
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8. HEALTH CARE FRAUD:
TYPES
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Source: THORNTON, e.a., Categorizing and Describing
the Types of Fraud in Healthcare, 2015

9. FRAUD AND ABUSE:
A PICTURE OF A BROAD LANDSCAPE
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Source: EHFCN

10. FINANCIAL IMPACT
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11. COMBATING FRAUD
A essential element for good governance health
systems:
• Rules
• Tools
• Manpower
• Cooperation
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12. THE BELGIAN EXPERIENCE:
MAIN TRENDS
• From incidental, anecdotal interventions to
strategic, robust and integrated approach
• From exclusive top down strategy to active and
responsible partnerships
• From a vision unilateraly based on criminal law to
a multidimensional policy
• From primitive datasets to more sophisicated
databases, datalinkage and datamining
• From national dimension to international
cooperation
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13. THE BELGIAN EXPERIENCE:
GENERAL FEATURES
- Primary control: sickness funds; second line: NIHDI
- Specific department of medical evaluation and control of NIHDI,
organised on a multidisciplinary basis and associated in establishing
legislation
- Triple mission
• Information for providers (e.g. ‘infobox’)
• Control: reality and conformity checks as well as
overconsumption (not easy!)
• Evaluation (feedback mirror for providers and impact analysis)
- Yearly ‘ICE’ program
- Research and investigation capacity (direct access to claims data
and medical files)
- Fast and efficient procedures (e.g. suspension payments),
specialised jurisdictions
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14. ANTI
FRAUD/CORRUPTION
CULTURE
DETERRENCE
PREVENTION
DETECTION
INVESTIGATION
SANCTIONS
REDRESS
PROBLEM
STRATEGY
STRUCTURE
ACTION
DELIVERY
Progressive, sustained and
integrated approach
Copyright Jim Gee 2009

15. PROGRESSIVE, SUSTAINED AND
INTEGRATED APPROACH
1. Prevention
- Definition benefits to be reimbursed, including
reimbursement conditions, pricing and tarriff setting
- Information (individual, professional groups,
academia, media, ...)
- Professional education and peer review
- Benchmarking and mirroring
- Feedback (individual; groupwise)
- Call to account providers
- Monitoring individual providers
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16. PROGRESSIVE, SUSTAINED AND
INTEGRATED APPROACH
2. Investigation
- Evaluate allegations or suspicions
- Conduct background checks and collect data
- Look to additional evidence: interview witnesses,
access to relevant medical files, ...
- Interview primary subject
- Make final report
- Decide what action to take: warning, settlement,
administrative sanction, recuperation or referral
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17. PROGRESSIVE, SUSTAINED AND
INTEGRATED APPROACH
3. Enforcement
- Recuperation and claw back
- Sanctions:
• Administrative sanction
• Suspend payments; third payer billing; impose
prior authorisation; suspend license to practice;
• Referral to criminal law jurisdiction
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18. THE BELGIAN EXPERIENCE:
CONCRETE EXAMPLES
- Introduction unique barcode pharmaceuticals
- Billing in emergency units
- Assessment autonomy patients in home care
- Repetitive protective dental care
- Upcoding CT scans rock bones / Carpal tunnel
treatment
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19. THE BELGIAN EXPERIENCE:
NEW DEVELOPMENTS
- Creation of interdepartemental unit appropriate
care (e.g. low back surgery; medical imaging; ...)
- SLA with departement justice
- Project on data mining methodology
- Transparancy for patients in case of electronic
third payer billing; compulsory use of eHealth
identification
- Review financial incentives
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20. COMBATING FRAUD AND ABUSE:
CRITICAL SUCCESSFACTORS
- Prevention (awareness, information, clear and fraud
tested legislation, ...)
- Deterrence: sufficient investigation and prosecuting
capacity (quantity and quality)
- Structured approach based on risk analysis
(“not only lucky shots”)
- Tailored and fast interventions and appropriate
sanctions and claw back procedures
- Cooperation with different stakeholders (justice;
providers; patients; ...)
- Data availability
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A BIG CHALLENGE: HOW TO REDUCE
INAPPROPRIATE AND LOW VALUE CARE ?

22. A BIG CHALLENGE: HOW TO REDUCE
INAPPROPRIATE AND LOW VALUE CARE ?
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Source: Colla C., NEJM, October 2014, 1280

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A BIG CHALLENGE: HOW TO REDUCE
INAPPROPRIATE AND LOW VALUE CARE ?

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A BIG CHALLENGE: HOW TO REDUCE
INAPPROPRIATE AND LOW VALUE CARE ?

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A BIG CHALLENGE: HOW TO REDUCE
INAPPROPRIATE AND LOW VALUE CARE ?

26. POSSIBILITIES OF INTERNATIONAL
COOPERATION
EHFCN
- Not for profit organisation (NIHDI cofounder and hosting
secretariat)
- Established in 2005
- Network of governmental authorities, health insurers,
counter fraud investigation units
- 12 European memberstates involved
Quid OECD ?
- Stimulate good practices
- Support and align data standardisation
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27. EHFCN
HTTPS://EHFCN-POWERHOUSE.ORG/
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28. THANK YOU FOR YOUR
ATTENTION !
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