The Control Office of the Mutual Health Funds and the National Unions Mutual Health Funds
The Control Office of the mutual health funds and the national unions of mutual health funds was created in 1990. It is a public interest institution under the guardianship of the Ministry of Social Affairs. A mutual health fund is a private non-profit association of individuals aiming at promoting the physical, psychological and social well-being, within a spirit of providence, mutual assistance and solidarity.
It is managed by a Council, composed by a chairman and six members named by the King for a renewable period of six years: two members chosen among the civil servants of the National Institute for sickness and disability insurances; one member designated by the Banking and Financial Commission; three members chosen on behalf of their legal, social, financial or actuarial skills.
Besides taking part in the execution of the compulsory insurance, the mutual health funds must at least organise a service of free or complementary insurance in order to intervene financially in favour of their members in the cost for prevention and treatment of sickness and invalidity, or allow benefits in case of disablement or when the situation is such that the physical, mental or social welfare can be improved. Additionally, they must supply aid, information, guidance and assistance in order to improve the physical, mental or social welfare.
The National Institute for Health and Disability Insurance (RIZIV/INAMI)
The National Institute for Health and Disability Insurance (INAMI) organises and financially manages healthcare insurance in Belgium.
From within INAMI the Service for Medical Evaluation and Control (SECM) is developing highly efficient systems and tools of evaluation, prevention, detection and investigation of improper use of the federal healthcare resources (€18 billion) by healthcare providers and suppliers. This results in active surveillance of good medical practice and the imposition of appropriate sanctions. Joining the Network has allowed INAMI to adopt “best practices” in tackling healthcare fraud in Belgium and throughout Europe.
The Intermutualistic Agency (NIC/CIN)
The Nationaal Intermutualistisch College is an organisation in which all Belgian Sick Funds are represented. The most important role of a Sick Fund is to execute or to carry out all legal dispositions concerning the Belgian health insurance. This primarily means: managing a sizeable membership administration, reimbursing healthcare bills from all kinds of healthcare providers, and paying benefits in case of an incapacity to continue working as a contracted labourer, employee, or self-employed. These expenses are funded by Government advancement. Sick Funds must provide detailed information to the government in order to justify their expenses. Sick Funds are paid a certain fee by the Government to perform these tasks. In addition to these important tasks, every Sick Fund provides a variety of services and benefits, for which the Sick Funds ask a membership fee.
All Belgian citizens must be member of a Sick Fund of their own choice, or by default will automatically become member of a Sick Fund service provided by the government. Because Sick Funds have mutual interests, face the same problems and challenges, it is only logical they should consult with each other on different levels. The Nationaal Intermutualistisch College is the highest level of consultation between Belgian Sick Funds.
Vanbreda International has over 50 years of experience in designing, implementing and managing cross-border medical insurance and employee benefits programmes and products for international organisations, multinational corporations and their international workforce.
With 420 employees, our company has its headquarters in Belgium and offices and representations in Europe (Italy and Switzerland), the Middle East (United Arab Emirates), Africa (Kenya, South Africa), Asia (Malaysia), Latin America (Chile) and North America (Florida, USA).
Vanbreda International serves around 430,000 plan members on a 24/7 basis in 192 countries. Every year the company processes more than 4 million medical bills for an amount of approximately 490 million EUR/640 million USD.
Vanbreda International is part of Cigna, a US-based global health service company.
VZP - General Health Insurance Company of Czech Republic
The General Health Insurance Company of Czech Republic is the biggest health insurance company in the Czech Republic. VZP ČR has been operating for over 15 years and has been one of the basic pillars of the Czech healthcare system for a long time. The company is a partner of renowned new-logo-VZPexpert associations and is a highly regarded member of the Association of International Non-profit Making Health and Sick Benefit Insurance Companies (Association Internationale de la Mutualité).
Regardless of clients‘ social situation, VZP ČR pays healthcare for them which has been provided on the territory of the Czech Republic and in EU member countries – it helps with any health situation. It ensures non-infringement of human, patient and insurance rights of clients. VZP ČR is capable of covering the most demanding medical operations.
In addition to health care, VZP ČR also focuses on health programmes and other preventive actions whose goal is to prevent serious diseases; it emphasizes prevention and a healthy lifestyle.
HENNER is the leading French consulting and third party administration Group with over 60 years experience, that designs, implements, provides advisory and administration of employee benefits schemes for corporate companies, cross-borders, international organizations and individuals.
HENNER’s 1,100 employees support 7000 clients and 135,000 individuals, for a total of 1.3 million beneficiaries including 232,000 international beneficiaries living in 198 countries and process annually average of 24.4 millions claims through established platforms in France, Switzerland, Tunisia, Kenya, Brazil, Canada and Singapore.
As a family-owned company, HENNER has demonstrated stability, as well as independence from major players in the market. One of HENNER’s main focuses is long-term client satisfaction and their financial protection. To do so, our major priority is to detect, prevent and combat fraudulent activity.
Transparency International, German Chapter, Working Group on Health
Transparency International, the global civil society organisation leading the fight against corruption, brings people together in a powerful worldwide coalition to end the devastating impact of corruption on men, women and children around the world.TI's mission is to create changes towards a world free of corruption.
Transparency International challenges the inevitability of corruption, and offers hope to its victims. Since its founding in 1993, TI has played a lead role in improving the lives of millions around the world by building momentum for the anti-corruption movement. TI raises awareness and diminishes apathy and tolerance of corruption, and devises and implements practical actions to address it.
Transparency International is a global network including more than 90 locally established national chapters and chapters-in-formation. These bodies fight corruption in the national arena in a number of ways. They bring together relevant players from government, civil society, business and the media to promote transparency in elections, in public administration, in procurement and in business. TI's global network of chapters and contacts also use advocacy campaigns to lobby governments to implement anti-corruption reforms.
Politically non-partisan, TI does not undertake investigations of alleged corruption or expose individual cases, but at times will work in coalition with organisations that do.
TI has the skills, tools, experience, expertise and broad participation to fight corruption on the ground, as well as through global and regional initiatives.
Now in its second decade, Transparency International is maturing, intensifying and diversifying its fight against corruption.
CNS “d'Gesondheetskeess” – the National Health Fund
The Luxembourg National Health Fund (Caisse nationale de santé or 'Gesondheetskeess', CNS) is the central contact point for all insured persons in the private sector (employees and other workers, such as self-employed workers) as well as public sector workers, for health insurance and long-term care insurance. The role of the CNS covers the settlement of:
- payments in kind (reimbursement of health care paid for by the insured person);
- payments in cash (maternity allowance, sickness benefit after the continuation of salary payments, funeral payments, etc.);
- long-term care insurance.
The CNS resulted from the merger of the Union of Health Insurance Funds (Union des caisses de maladies, UCM) and the 6 former private-sector health insurance funds gathering the private sector workers' (CMEP), manual workers' (CMO), Arbed employees' (CMEA), Arbed manual workers' (CMOA), agricultural workers' (CMA), liberal professions' (CMPI). The CNS covers the activities of the different merged institutions:
- the sickness benefits department handles all the sick leave declarations from private-sector employees. Medical certificates must be sent to the head office of the CNS, in order to receive payments in cash;
- the payments in kind department is responsible for reimbursing medical expenses paid by insured persons;
- the (long-term care insurance) services department centralises long-term care insurance applications and settles the payments relating to long-term care in kind, in cash or using a combination of these, after the Assessment and Guidance Unit has evaluated the level of long-term care.
Zorgverzekeraars Nederland – Health Insurers Netherlands
Zorgverzekeraars Nederland (ZN) is an organisation representing the providers of healthcare insurZorgverzekeraars-Nederlandance in the Netherlands. Its main activity is achieving conditions within which members can operate in an optimal manner.
The primary task of ZN is to promote the interests of its members. This refers not only to supporting and providing services, such as the provision of information and PR, but also conducting collective bargaining (CAO) negotiations and representing members in bodies such as the Health Service Tariff Tribunal (College Tarieven Gezondheidszorg) and the Building Council (Bouwcollege).
ZN was formed in 1995 following a merger of the VNZ (Association of Dutch Statutory Health Insurers) and the KLOZ (contact body for the national organisations of private health insurance funds). Since the merger, ZN has has taken a pro active role in all matters concerning the health service, meeting with representatives of the state, the national organisations of health providers, and the patient/consumer associations.
ZN plays an active role in the national debate on the structuring of the healthcare insurance system, the supply of healthcare facilities and the quality of these facilities.
Whilst the individual health insurers hold the central position in efforts to countering fraud ZN has developed an anti-fraud policy to:
- coordinate the development of policy
- bring together all anti-fraud officers who work within health insurance companies (on the Anti-fraud Platform)
- develop instruments and techniques that can be used (for example, a report about the possibilities for sanctions)
- coordinate meetings between anti-fraud officers to encourage the exchange of ideas, experiences and actual cases of fraud.
Furthermore, ZN examines randomly gathered copies of bills sent in by hospitals and doctors, to see how they comply with the regulations and to advise the health insurers on how to improve their control systems. The results of these random checks are then discussed within a working group.
HELFO – the Norwegian Health Economics Administration
The Norwegian Health Economics Administration (HELFO) is a sub-ordinate institution directly linked to the Norwegian Directorate of Health.
The annual budget of €2.65 billion includes:
- direct payments to various health service providers
- individual reimbursement for certain medicines, dental services and health services abroad.
In addition, HELFO has in charge the regular GP scheme, which entitles one to have a regular GP, and the issuance of The European Health Insurance Card.
HELFO currently has about 600 employees among the Main Office, 6 Regional Offices distributed throughout Norway, the Patient Referral Unit and a Service centre.
The Ministry of Health
The Ministry of Health is a policymaker and the regulatory body. The Ministry is responsible for national health policy, for major capital investments, and for medical science and education. It is also responsible for implementing national public health programmes, for training health care personnel, for funding medical equipment and for setting and maintaining health care standards. It has also a number of supervisory functions over different units and national institutions.
IGAS - General Inspectorate of Health
The Ministry of Health is the government agency whose mission is to define the national health policy, practice standards and the corresponding functions to promote their implementation and evaluate the results.
Its tasks include: igas
- Ensuring the necessary actions for the formulation, implementation, monitoring and evaluation of health policy;
- Exercising the regulatory functions, planning, funding, guidance, monitoring, evaluation, audit and inspection on the National Health Service;
- Exercising regulatory inspection and supervision on the activities developed by the private health sector which are not integrated in the health system, including the professionals involved.
ZZZS - Health Insurance Institute of Slovenia
The Health Insurance Institute of Slovenia was founded on March 1, 1992 and conducts its business as a public institute, bound by statute to provide compulsory health insurance.
The Institute's principal task is to provide effective collection and distribution (allocation) of public funds, in order to ensure the insured persons quality rights arising from the said funds. The rights arising from compulsory health insurance, furnished by the funds collected by means of compulsory insurance contributions, comprise the rights to health care services and rights to several financial benefits (sick leave pay, reimbursement of travel costs and funeral costs, and insurance money paid in case of death).
The Institute is governed by an Assembly, whose members are the (elected) representatives of employers (including the representatives of the Government of the Republic of Slovenia) and employees. The executive body of the Assembly is the Institute Board of Directors.
In 2008, the total Institute expenditure in the realisation of the compulsory health insurance was approximately 2,21 billion EUR. This amount refers to the expenditure of (public) funds, collected on the basis of contributions paid by employers and employees, and by several other categories of contributors.
The Sub-Direcorate General for Healthcare Evaluation and Inspection
The Sub-Directorate General for Healthcare Evaluation and Inspection, which forms part of the Catalan Health Ministry and is attached to the Directorate-General for Health Planning and Regulation, has as a mission the study and assessment of the healthcare system and the proposal of any necessary measures, within the legal framework and with a view to improving services, in order to guarantee the safety and efficacy of the services and the personal rights of users.
Its functions, established by law, includes the following: assess, inspect and control healthcare resources to ensure that quality standards are maintained and that healthcare centres and services comply with requirements concerning structure and operation and to investigate functional and economic anomalies within the healthcare system.
The Sub-Directorate General’s “map” of operational processes includes the following actions
- Investigation into complaints and reports related to healthcare
- Investigation into healthcare fraud
- Verification of compliance with legal requirements and quality standards.
- Investigation as part of administrative disciplinary proceedings.
In order to carry out the tasks, related with fraud, the Sub-Directorate General has the Healthcare Inspection Service that develops the following specific functions:
a. To detect any anomalies in operation that may favour illicit behaviour or lead to fraud or damage to the interests of the healthcare system, and,
b.To detect, investigate and compile documentary evidence and information on matters concerning financial misleading and to take disciplinary actions over any cases detected.
Business Services Organisation, Northern Ireland
Established in April 2009 the Business Services Organisation provides a broad ralogo-HSC-bsonge of regional business support functions and specialist professional services to the Health and Social Care sector in Northern Ireland.
Falling under the umbrella of the Operations Directorate, the remit of Counter Fraud and Probity Services (CFPS) includes:
- tackling fraudulent claims made by patients in respect of statutory dental and ophthalmic charges;
- the formal investigation of cases of suspected fraud across all Health and Social Care organisations. Examples include falsely claiming for travel subsistence or hours worked, the theft of cash or equipment and false accounting
- the delivery of a range of probity verification and assurance work in relation to Primary Care contractors. These verification checks can include post payment verification visits to practices, checking clinics and practice record reviews.
- counter fraud and probity policy
- fraud awareness – this work involves raising awareness amongst HSC staff through the development of an elearning package and complimentary promotional materials and the creation of new fraud reporting tools for staff and the general public.