E.2. Health Benefits | International Social Security Association (ISSA)

Introduction
Objectives of the ISSA Guidelines on Error, Evasion and Fraud in Social Security Systems
Compliance Risk Management Model: A Six-Phase Continuous Loop Process
Structure of the ISSA Guidelines on Error, Evasion and Fraud in Social Security Systems
A. Governance
Guideline 1. Mandate, powers and responsibilities of the board
Guideline 2. Strategic planning
Guideline 3. Plan for coordination and collaboration at inter-institutional, national and international level
Guideline 4. A common platform of coordination for all schemes and branches
B. Strategy
Guideline 5. Framework adapted to address error, evasion and fraud
Guideline 6. Establish objectives and indicators to address error, evasion and fraud
Guideline 7. Measuring the potential impact of error, evasion and fraud
Guideline 8. Managing continuous improvement: Evaluating performance against objectives and taking corrective measures
C. Operational Processes Common to All Social Security Branches and Risks
Guideline 9. Ensuring unique identification
Guideline 10. Develop a culture and techniques for internal control
Guideline 11. Organize the internal audit function and its supervision
Guideline 12. Develop an external audit function using one or more control bodies
Guideline 13. Developing the institutional capacity for a massive use of external data
Guideline 14. Reducing risks related to financial flows
Guideline 15. Reducing error related to failure to claim benefits
Guideline 16. Sanctioning fraud
D. Error, Evasion and Fraud Risk Management in the Contribution Collection Process
Guideline 17. A strategy to address error, evasion and fraud in the collection of contributions
Guideline 18. Automated system for the management and execution of error, evasion and fraud control measures in the contribution collection process
Guideline 19. A systematic approach to litigation management in the event of error, evasion and fraud in the collection of contributions
Guideline 20. Evaluating the results of the contribution collection policy
E. Operational Processes Specific to Addressing Fraud in the Various Risks Covered by Social Security
E.1. Family and Housing Benefits
Guideline 21. Adequate organizational structure for family and housing benefits
Guideline 22. Detection and deterrence
E.2. Health Benefits
Guideline 23. Adequate organizational structure for health benefits
Guideline 24. Social security membership rights and compliance with healthcare regulations
Guideline 25. Detection and deterrence
E.3. Occupational Risks, Unemployment, Old-Age and Disability Benefits
Guideline 26. Occupational risks and vocational rehabilitation
Guideline 27. Unemployment benefits
Guideline 28. Old-age and disability benefits
F. Promoting the Proper Use of Social Security Systems and the Results of Addressing Fraud
Guideline 29. Facilitating understanding of social security to promote action against error
Guideline 30. Communicating the results of detecting and preventing error, evasion and fraud
Guideline 31. Developing public messages about the social costs of error, evasion and fraud
Guideline 32. Reporting cases of non-compliance and fraud
Guideline 33. Developing incentives to tackle error, evasion and fraud by allowing financial compensation to be reinvested in actions to detect and prevent them
Guideline 34. Developing a culture of ethics among leaders and staff
G. Coordination with Other Institutional Actors
Guideline 35. Partnerships are crucial to improve the efficient detection and prevention of error, evasion and fraud
Guideline 36. Data sharing outside the social security system, between national institutions and other public services
Guideline 37. Data sharing with foreign social security institutions to prevent the risk of error, evasion and fraud
Acknowledgements

The financing of health benefits is an important element of social security expenditure.

Addressing error, evasion and fraud in health benefits should focus on several specific risks:

In terms of error and evasion, to ensure the correct enrolment of individuals and the compliance with healthcare regulations;
In terms of fraud, the diversion of monetary payments, instigated by employers or employees;
Fraud related to in-kind payments, instigated by health providers and patients.

ISSA Guidelines:

Error, Evasion and Fraud in Social Security Systems

ISSA Guidelines:

Error, Evasion and Fraud in Social Security Systems

Error, Evasion and Fraud in Social Security Systems -
E.2. Health Benefits

Error, Evasion and Fraud in Social Security Systems - E.2. Health Benefits

Error, Evasion and Fraud in Social Security Systems

Error, Evasion and Fraud in Social Security Systems -
E.2. Health Benefits