Documents
The CMS is pleased to announce that the inaugural Fraud, Waste and Abuse Summit will be held at the Sandton Convention Centre, in Johannesburg on 28 February - 1 March 2019.
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Documents

Industry Codes of Good Practice

The CMS Industry Charter against fraud, waste, and abuse (FWA) in the healthcare sector was concluded and adopted by stakeholders in March 2019.

The stakeholders include regulators, healthcare funders, administrators, medical scheme industry representatives, and professional associations. This Code of Good Practice (CoGP) maintains the objectives, definitions, and principles of the Industry Charter on FWA.

The Health Funders Association compiled and developed this CoGP as envisaged in section 16 of the Charter, in that: 

“Administrators, MCOs and Medical Schemes shall prepare an Industry Code of Good Practice for regulatory input and approval that will govern their conduct when it comes to dealing with matters of FWA.” 

This CoGP is developed under the custodianship of a suitably representative industry organisation, and its members will review it periodically. 

FWA Code of Good PracticeDownload

FWA Tribunal Rules

The Fraud, Waste and Abuse Tribunal is established to resolve complaints lodged in relation to the prevention, detection, investigation, sanction, or restitution of funds under section 59 of the Medical Schemes Act, (131 of 1998) (MSA), read with Regulations 5 and 6 to the MSA, which may involve members of the medical schemes, service providers, and medical schemes.

The Fraud, Waste and Abuse Tribunal Rules are to provide for the functions and powers of the Fraud, Waste and Abuse Tribunal; for application of penalties to be applied to a medical scheme or administrator in respect of late payment of benefits owing to a member or services in contravention of section 59(2) of the MSA as contemplated under section 67(1)(o) of the MSA; for reporting of acts or omissions of any person in contravention of the provisions of the MSA as envisaged under section 67(1)(p) of the MSA; to provide for the protection and promotion of rights on charges and payment of claims as contemplated under section 59 read with Regulation 6 to the MSA; for coordinating penalties imposed in terms of section 42(1) of the Health Professions Act, 1974 (Act 56 of 1974) against a health professional.

FWA Tribunal Rules Download