Break-out B Fraud Management in Social Security

Fighting Fraud in Healthcare and
Social Security:
How to maximise resources?
Break-out Session B
Fraud Management in Social Security
Thursday 6th of October
2
EUROPEAN HEALTHCARE FRAUD AND
CORRUPTION NETWORK
Fraud Prevention and Deterrence
Maggie Worsfold
NHSScotland Counter Fraud Services
3
NHS Scotland Counter Fraud Services
• Established in 2000 to tackle fraud by patients and
primary care contractors in Scotland – reactive
investigations and patient exemption checking
• Centrally funded by Scottish Government
• Role extended in 2004 to secondary sector with a
remit for proactive and communications work
• Health budget in Scotland is £11 billion for a
population of 5 Million
4
Government Strategy
Proactive Investigations and Exercises
• Operation Gold
– Precious metal restorations
• FHS toolkits
– for dental, ophthalmic, pharmacy, enabling the
identification of high risk areas where fraud is more likely
to occur
• Operation Thyme
– eMas – pharmacy registration capitation fees and potential
for false claims for medication
• Statistical monitoring of national trends and outliers
Proactive Actions
• Issue intelligence alerts to all Health Boards and
stakeholders
• Recommend legislation changes to Scottish
Government Health Directorates
• Highlight frauds to professional representative
bodies e.g. Royal College of Nursing, Optometry
Scotland, BDA Scotland
• Deliver workshops to relevant staff within health
arena to demonstrate areas of risk
Communications
• Fraud Awareness Sessions/Workshops
• e-Learning package to reach all staff
• Training DVDs, workshops and seminars
• Adverts for Intranets and Internets
• Networks
– Counter Fraud Champions and Fraud Liaison Officers
– EHFCN
• Pro-active publicity for successful prosecutions
• A part time administration assistant, was jailed for 8 months,
after she admitted to defrauding NHS Scotland of almost
£40,000.
• Joanne Jamieson, 40, was sentenced at
Glasgow Sheriff Court.
• She claimed for hours she had never worked in her
administration role, in addition to her other job as a
cleaner, at the city's Stobhill Hospital.
* Picture courtesy of Daily Express
• An anaesthetic assistant was jailed for 20 months for stealing
vast amounts of medical supplies, including specialist surgical
implants and skull drill bits, worth more than £23,000 which he
then tried to sell on eBay.
• Douglas Stevenson, 31, was sentenced during an appearance at
Glasgow Sheriff Court.
• He stole the equipment while working at Glasgow’s Royal
Hospital for Sick Children, the Southern General and Royal
Infirmary between Oct 2006 and Nov 2008.
Picture courtesy of The Scottish Sun
The Value of Press Coverage
• In the current economic climate the value of publicity around
CFS cases cannot be underestimated.
• The Douglas Stevenson case attracted extensive media
coverage which included features in; The Herald, Scottish Sun,
Daily Record, Daily Express, BBC, STV.
The equivalent space in paid advertising
would equate to £152,500 !
Internet Advert
• Identifies types of fraud perpetrated by NHS staff
CFS Action Plan
• Four Ds
– Deter
– Detect
– Disable
– Deal with
• Efficient deterrence delivers savings - £4
million in 2010/11
Fighting Fraud in Healthcare and
Social Security:
How to maximise resources?
Fraud Management –
London Borough of Brent
Tony Ellis
15
About Brent
16
What does a London Council do

Refuse
Collection

Regeneration
Libraries
We Provide 600+ Services

Council Tax

Local Benefits

Parks

Street Care
to Residents & Businesses

Citizenship

Births,
deaths
85% of all Government Services
Schools
& marriages

Housing

Parking

Adult Care

Licensing

Children’s Care

Roads

are via local councils
17
Business Challenge
18
CRM
98997645
Freddie Bloggs
ER
98997645
Freddie Bloggs
CTAX
AA347987
Freddie Boggs
HOUSING
0012345
Fred Bloggs
BENEFITS
44576
Freddie Boggs
BLIND
CHILDREN
zz345543
Frederick Bloggs
ADULT CARE
555777777
Fred Bloggs
LIBRARY
8788GHB
F Bloggs
MYDEX
0000707
Fred Bloggs
E-FORMS
7877767
Fred Blogs
19
CRM
98997645
Freddie Bloggs
ER
98997645
Freddie Bloggs
CTAX
AA347987
Freddie Boggs
HOUSING
0012345
Fred Bloggs
BENEFITS
44576
Freddie Boggs
ChangeBLIND
in Circs
Master Customer
Database
- Name
- Address
- Deceased Date
- Phone no.
- Email
 Key Customer Data
 Back Office
Reference Numbers
 Basic Service
Info/Attributes
CHILDREN
zz345543
Frederick Bloggs
ADULT CARE
555777777
Fred Bloggs
LIBRARY
8788GHB
F Bloggs
MYDEX
0000707
Fred Bloggs
E-FORMS
7877767
Fred Blogs
20
FIELDS
HB
CRM
HSD
ER
ADULTS
GOLDEN
Full Name
Fred Smith
Freddie Smith
Frederick Smith
Fred Smith
Fried Smith
Fred Smith
DOB
10-1-1965
10-1-1965
10-1-1965
M
M
10-1-1965
Gender
M
M
M
M
Address
10 The Grange
Chigley
TR8 1AA
Flat A
10 The Grange
Chigley
TR8 1AA
10 The Grange
Chigley
TR8 1AA
Flat A
10 The Grange
Chigley
TR8 1AA
1007689
00074321
899743
30005632A
Reference
NINO
Customer Care Ind
1007689
AB123456B
0205-937-996
0205-937-996
07988674707
07988674707
fsmith@vir.com
Email
Income Support
7221900
AB123456B
Home Tel
Mobile
Flat A
10 The Grange
Chigley
TR8 1AA
fsmith@vir.com
Y
Y
Disabled
Blue Badge
Disabled Blue Badge
21
HOUSEHOLD
FIELDS
HB
PUPIL
HSD
ER
ADULTS
LIBS
Elizabeth Smith
Johnny Smith
Liz Smith
David Hughes
Albert Smith
Johnnie Smith
25-11-1950
24-3-2001
25-11-1950
28-1-1917
10-1-1965
Gender
F
M
F
F
M
M
Address
10 The Grange
Chigley
TR8 1AA
Flat A
10 The Grange
Chigley
TR8 1AA
10 The Grange
Chigley
TR8 1AA
Flat B
10 The Grange
Chigley
TR8 1AA
1007689
A98976570089
899743
884198
Full Name
DOB
Reference
NINO
0205-937-996
School
662890A
0205-937-996
0744786435
12-04-2011
Deceased
Person End
Date
Income Support
27689
AB123456B
Home Tel
Mobile
Flat A
10 The Grange
Chigley
TR8 1AA
Y
Waterloo High
Chigley
TR8 2DD
Disabled
Blue Badge
22
Results

Major contribution to identifying £1.2m local tax fraud

Identification and detection of fraud in following areas:
- Sub-letting council properties (est £2bn fraud in UK)
- Housing Benefit fraud (£2.5m in Brent 2010/11)
- Blue Badge for disabled parking (badge worth £10k in London)
- Training Grant fraud
- School Admissions
- Unpaid Parking fines

Fraud Team feedback about use of IBM Initiate (Client Index)
- Used in every job
- Thousands of searches
- Immediacy
- Accuracy
- The complete picture
23
THANK YOU
Tony Ellis
tonyellis@uk.ibm.com
+44 7887 632031
24
Fighting Fraud in Healthcare and
Social Security:
How to maximise resources?
EUROPEAN HEALTHCARE FRAUD AND
CORRUPTION NETWORK
Dariusz Śpiewak
Social Insurance Institution (ZUS)
1
Registration procedures - NOW
Opening of contribution payers' accounts based on the unique tax identification
number (NIP) using data obtained from KEP (a database which is updated offline,
on a monthly basis).
Introduction of "one-stop-shop" has limited opportunities of shady practices and
reduced a number of cases where contribution payers failed to report to ZUS.
Thanks to recent introduction of an electronic business registration application
(CEiDG) ZUS receives on-line information about registered new companies.
Establishment of insured persons' accounts (Polish citizens), based on their
statistical identification number (PESEL), using data from PESEL register
(including family name). Currently the database is updated offline on a monthly
basis.
Taking advantage of information about the death of the insured / beneficiary
received from PESEL register. As a result of monthly update of PESEL database,
information about death is processed with delay which causes sporadic cases of
2
undue payment of benefits after death.
Registration procedures - IN FUTURE
Establishment of the database - the Central
Register of ZUS Customers.
Establishment of the Central Register of ZUS Customers will not result in the
change of registration procedures, but will contribute to more effective use of
information and data obtained during registration.
Direct access to PESEL database and verification of benefit recipient's data in
payment applications should contribute to more effective detection of
irregularities consisting in payment of undue benefits.
Direct access to KEP database will streamline the verification process of unique
tax identification number (NIP).
3
Data exchange with external institutions NOW
Transmission of information from ZUS to the National Disabled Persons
Rehabilitation Fund (PFRON) about contribution payers and beneficiaries who
satisfy the conditions for a refund of contributions,
The interface with the Open Pension Funds (OPFs), which allows to communicate
information on applications / updates / de-registration of OPF members. It also
allows to check the accuracy of data provided by agents, concerning individuals
who entered into an agreement with OPF.
Providing the National Health Fund with information about people covered by the
health insurance.
Exchange of data on pension benefits with the Agricultural Social Insurance Fund
(KRUS), National Depository for Securities, Ministry of Finance, Central Statistical
Office, Ministry of Defence, Ministry of Interior is asynchronous.
4
Data exchange with external institutions - IN
FUTURE
In terms of data exchange with external institutions, such as
Ministry of Defence, KRUS, Ministry of Interior, the online solution is planned,
based on open communication standards (such as webservice).
In the context of more effective enforcement of dues this will inter alia enable
integration with other registration systems (e.g. the Central Registry of Vehicles
and Drivers "CEPIK").
It is also planned to sign an agreement with the Ministry of Justice with regard to
access to the electronic land registry.
5
Control procedures - NOW
Selecting patients and physicians for checking sick leaves.
Control of contribution payers who pay allowances from the sickness or accident
insurance and employ pregnant women with high insurance contributions.
6
Control procedures - IN FUTURE
medical e-certificates
The target is to eliminate the practice of forging paper forms of medical
certificates. Functional solutions of the system will allow to reduce the number of
violations by physicians of certification rules, such as: issuing medical
certificates for retrograde period (except for cases allowed by legislation), failing
to enter statistical numbers of diseases.
This will allow to reduce the number of cases where errors in medical certificates
need to be explained.
More effective verification of short periods of incapacity for work (currently a
paper ZUS ZLA form may be submitted within 7 days).
Control of contribution payers
Establishment of the Central Register of ZUS Customers (CRKZ) will also allow to
introduce a comprehensive risk analysis module for selecting candidates for
inspection.
7
Databases - NOW
In terms of unreformed benefits, existence of distributed databases poses a
risk of claiming the old-age pension in different ZUS branches. In this respect,
campaigns are carried out to detect the same PESEL numbers in separate
databases.
Databases - IN FUTURE
Integration of benefit records into the central database is carried out.
Eventually no distributed databases will exist. There will be no need to carry
out verification in order to detect duplicate entities and related benefits,
because the process will be fully systemic.
8
Thank you
9
Fighting Fraud in Healthcare and
Social Security:
How to maximise resources?
Fighting fraud in healthcare and social
security
Marek Ujejski –
Deputy Director IT Department National Health Fund,
POLAND
marek.ujejski@nfz.gov.pl
Kraków, 6-7 October 2011
Kraków, 6-7 October
2011
Association of Certified Fraud Examiners stated
in 2008 Report to the Nation on Occupational
Fraud and Abuse
The ACFE 2008 report estimates that a typical organization loses
seven percent of its annual revenues as a result of occupational
fraud and abuse. To illustrate the potential enormity of typical
fraud loss, ACFE applied the seven percent figure to the
estimated 2008 United States Gross Domestic Product —
translating to about US $994 billion in fraud losses.
Kraków, 6-7 October 2011
Kraków, 6-7 October
2011
Kraków, 6-7 October
2011
Landscape of Poland 1
Kraków, 6-7 October
2011
Landscape of Poland 2
Kraków, 6-7 October
2011
Landscape 3
Kraków, 6-7 October
2011
POLAND – some facts
Area
Number of
citizen
POLAND – some facts
Number of
medical units
Refund cost
of medical
treatments
National income versus expenditure for
medical services
55 000
50 000
45 000
Wydatki KCh i NFZ wobec PKB
Insurance expences as overall
versus national income per capita
wydatki KCh/ NFZ [mln zł]
PKB na 1 mieszkańca [zł]
Liniowy (wydatki KCh/ NFZ [mln zł])
Liniowy (PKB na 1 mieszkańca [zł])
40 000
35 000
30 000
25 000
20 000
15 000
10 000
5 000
0
Kraków, 1999
6-7r October
2000 r
2011
2001 r
2002 r
2003 r
2004 r
Materials thanks to Jerzy Hajdas
2005 r
2006 r
2007 r
2008 r
2009 r*
How big is fraud volume in medical
insurance in Poland?
• Lack of trustable statistics, there are rather guess then
mathematically proven results
• Estimation based on worldwide experience- 5 to 10 %
dissapered
• Only top of iceberg is visible
• Wekness of process chain,however some spectacular
success had been achived
Kraków, 6-7 October
2011
Status of NFZ
Kraków, 6-7 October
2011
How we are organised ?
Kraków, 6-7 October
2011
What we have in IT
Infrastructure
Dolnoślaski
Headquater
In Warsaw
Podkarpacki
Wielkopolski
Mazowiecki
Łódzki
(p-series)
Śląski
Opolski
……………………
Małopolski
Tape Backup
Kraków, 6-7 October 2011
8 branches on HP Platform
8 branches on IBM Platform
……………………
What was done
•
•
•
•
•
•
•
•
•
Data exchange and verification
All data between NFZ and medical unit are exchanged via XML
structure data
Data are verified and validated, however…
…not digitaly signed
No ewidence that reported medical treatment has occur (lack
of data non-repudation)
Statistics are used for finding corelation between different
objects and behavior
Only headquaters is able to find cross country corelation
Hudge size of data volumen is a challenge
Scheme of fraud is constantly changed (Continuous evolution
of newer fraud schemes to bypass existing detection
techniques)
NFZ has 5 years for verification
How to build good system (by CPW)
•
Build a profile of potential frauds.
•
Test transactional data for possible indicators of fraud. A complete testing program
should include ad hoc or random testing in addition to more formalized or regular tests. The
spectrum of automated testing ranges from ad hoc through to repetitive through to
continuous.
•
Look for newer fraud mechanizm based on diffeerent statistic tools
•
mprove controls by implementing continuous auditing and monitoring. Strengthen
controls over transaction authorizations and use continuous auditing and monitoring to test
and validate theeffectiveness of your controls.
•
Review information from data testing and continuous auditing and monitoring.
Investigate patterns and fraud indicators that emerge from the fraud detection tests and
continuous auditing and monitoring.
•
Repeat the steps. This process of building a profile, testing data, improving controls and
reviewing information needs to be repeated on a regular basis.
•
Response. Create written reports with recommendations on how to tighten controls or
change processes to reduce the likelihood of recurrence.
Ministry
of interior
MSWiA
Karta Personelu
Profesional
Card
Medycznego (KPM)
Aplet w pl.ID realizujacy
funkcjonalność
HIC
aplet in KUZ
pl ID
1
5
UBEZPIECZONY
Patient
1- Verifing of document (CA+TA)
2- authorisation rights to medical
treatment (question to data base NFZ)
3-answer from data base NFZ (Yes, No)
4-creating description of medical
transaction
5- Proffesional signature (with PIN)
6-verificattion of certificate
7- electronical stamp (without PIN-u)
8-send encrypted XML document to NFZ
Kraków, 6-7 October
2011
Medical
LEKARZ
Professional
4
Certyfikat
Terminal
terminala
NFZ
certificate
2
3
6
7
NFZ
TOOLS-AN EXAMPLE
Kraków, 6-7 October
2011
Kraków, 6-7 October
2011
Kraków, 6-7 October
2011
Kraków, 6-7 October
2011