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SOUTH AFRICAN QUALIFICATIONS AUTHORITY 
REGISTERED UNIT STANDARD: 

Describe the control of fraud in Healthcare Benefits Administration 
SAQA US ID UNIT STANDARD TITLE
118018  Describe the control of fraud in Healthcare Benefits Administration 
ORIGINATOR
SGB Insurance and Investment 
PRIMARY OR DELEGATED QUALITY ASSURANCE FUNCTIONARY
-  
FIELD SUBFIELD
Field 03 - Business, Commerce and Management Studies Finance, Economics and Accounting 
ABET BAND UNIT STANDARD TYPE PRE-2009 NQF LEVEL NQF LEVEL CREDITS
Undefined  Regular  Level 4  NQF Level 04 
REGISTRATION STATUS REGISTRATION START DATE REGISTRATION END DATE SAQA DECISION NUMBER
Reregistered  2018-07-01  2023-06-30  SAQA 06120/18 
LAST DATE FOR ENROLMENT LAST DATE FOR ACHIEVEMENT
2024-06-30   2027-06-30  

In all of the tables in this document, both the pre-2009 NQF Level and the NQF Level is shown. In the text (purpose statements, qualification rules, etc), any references to NQF Levels are to the pre-2009 levels unless specifically stated otherwise.  

This unit standard does not replace any other unit standard and is not replaced by any other unit standard. 

PURPOSE OF THE UNIT STANDARD 
This unit standard introduces the concept of fraud and its control in Healthcare Benefits Administration and is intended for medical claims assessors and learners in Medical Scheme Administrators.

The qualifying learner is capable of:
  • Describing fraud as it occurs in a Healthcare Benefits Administration environment.
  • Explaining legal aspects relating to fraud Healthcare Benefits Administration.
  • Explaining internal processes relating to the investigation of fraud in Healthcare Benefits Administration.
  • Analysing trends and the impact of fraud in a Healthcare Benefits Administration environment.
  • Explaining control mechanisms used to contain fraud in a Healthcare Benefits Administration. 

  • LEARNING ASSUMED TO BE IN PLACE AND RECOGNITION OF PRIOR LEARNING 
    There is open access to this unit standard. Learners should be competent in Communication and Mathematical Literacy at Level 3. 

    UNIT STANDARD RANGE 
    The typical scope of this unit standard is
  • Parties who could commit fraud include, but are not limited to, employees, providers, policy holders, software houses/vendors, intermediaries and Trustees.
  • Fraudulent activity could be identified in claims, reports, phone calls, information received and other documents.
  • Legislation governing fraud includes the Medical Schemes Act, Income Tax Act, Health Professionals' Act, Long Term Insurance Act, Pharmacy Act, law of contract, Policy Holder Protection and FAIS legislation.
  • The impact of fraud on medical inflation includes, but is not limited to, patient rights, restrictions, scheme governance members, cost, quality and access. 

  • Specific Outcomes and Assessment Criteria: 

    SPECIFIC OUTCOME 1 
    Describe fraud as it occurs in a Healthcare Benefits Administration environment. 

    ASSESSMENT CRITERIA
     

    ASSESSMENT CRITERION 1 
    The concept of fraud is explained with authentic examples. 

    ASSESSMENT CRITERION 2 
    The relationship between over servicing and fraud is explained with examples. 

    ASSESSMENT CRITERION 3 
    Parties who could commit fraud are identified for Healthcare Benefits Administration environment. 

    ASSESSMENT CRITERION 4 
    Five possible indicators of fraudulent activity are listed and an indication is given of how these could be identified in practice. 

    SPECIFIC OUTCOME 2 
    Explain legal aspects relating to fraud in Healthcare Benefits Administration. 

    ASSESSMENT CRITERIA
     

    ASSESSMENT CRITERION 1 
    Legislation governing fraud is identified as it applies in Healthcare Benefits Administration. 

    ASSESSMENT CRITERION 2 
    The legal recourse available to Healthcare Benefits Administrators in cases of fraud are identified with authentic examples. 

    ASSESSMENT CRITERION 3 
    The consequences of committing fraud are explained for at least three different parties. 

    ASSESSMENT CRITERION 4 
    The impact of fraud is explained in relation to the healthcare system. 

    SPECIFIC OUTCOME 3 
    Explain internal processes relating to the investigation of fraud in Healthcare Benefits Administration. 

    ASSESSMENT CRITERIA
     

    ASSESSMENT CRITERION 1 
    The internal policy relating to fraud is described for a particular Healthcare Benefits Administrator or case study. 

    ASSESSMENT CRITERION 2 
    The procedure followed if fraud is suspected is explained with reference to a particular Healthcare Benefits Administrator or case study. 

    ASSESSMENT CRITERION 3 
    The process followed in order to gather evidence and present a case is described with reference to a particular Healthcare Benefits Administrator or a case study. 

    ASSESSMENT CRITERION 4 
    Tools that are available for information management are described with reference to a particular Healthcare Benefits Administrator or a case study. 

    SPECIFIC OUTCOME 4 
    Analyse trends and the impact of fraud in a Healthcare Benefits Administration environment. 

    ASSESSMENT CRITERIA
     

    ASSESSMENT CRITERION 1 
    A case study of a data set is compiled and trends in the data are identified to provide a benchmark against which to measure suspicious incidences. 

    ASSESSMENT CRITERION 2 
    Data is analysed to establish trends in statistics generated by an Healthcare Benefits Administrator. 

    ASSESSMENT CRITERION 3 
    A recommendation for possible corrective measures is made based on an identified trend or suspicious incidence. 

    ASSESSMENT CRITERION 4 
    The potential impact if fraud is not identified and managed is described with examples. 

    SPECIFIC OUTCOME 5 
    Explain control mechanisms used to contain fraud in Healthcare Benefits Administration. 

    ASSESSMENT CRITERIA
     

    ASSESSMENT CRITERION 1 
    Possible control measures that could be used to manage fraud are listed for at least three parties. 

    ASSESSMENT CRITERION 2 
    The risk if a Healthcare Benefits Administrator does not implement adequate control measures is explained with reference to the Healthcare Benefits Administrator, providers and members. 

    ASSESSMENT CRITERION 3 
    The role of a quality control programme is described in terms of managing fraud. 


    UNIT STANDARD ACCREDITATION AND MODERATION OPTIONS 
    This Unit Standard will be internally assessed by the provider and moderated by a moderator registered by a relevant accredited ETQA or an ETQA that has a Memorandum of Understanding with the relevant accredited ETQA. 

    UNIT STANDARD ESSENTIAL EMBEDDED KNOWLEDGE 
    N/A 

    UNIT STANDARD DEVELOPMENTAL OUTCOME 
    N/A 

    UNIT STANDARD LINKAGES 
    N/A 


    Critical Cross-field Outcomes (CCFO): 

    UNIT STANDARD CCFO IDENTIFYING 
    Learners are able to identify and solve problems in recommending possible corrective measures when suspicious incidences or trends are identified. 

    UNIT STANDARD CCFO WORKING 
    Learners are able to work as a member of a team in following procedures relating to fraud. 

    UNIT STANDARD CCFO ORGANISING 
    Learners are able to organise and manage themselves effectively by becoming responsible citizens in identifying incidences of fraud in a Healthcare Benefits Administration environment. 

    UNIT STANDARD CCFO COLLECTING 
    Learners are able to collect, organise and critically evaluate information in gathering evidence and presenting a case and to describe the control of fraud in a Healthcare Benefits Administration environment. 

    UNIT STANDARD CCFO COMMUNICATING 
    Learners are able to communicate effectively in explaining concepts and the consequences of fraud. 

    UNIT STANDARD CCFO SCIENCE 
    Learners are able to use science and technology effectively and critically showing responsibility towards the environment and the health of others in using a computer system as a management tool. 

    UNIT STANDARD CCFO DEMONSTRATING 
    Learners are able to demonstrate an understanding of the world as a set of related systems in understanding the effect of fraud in Healthcare Benefits Administration on different parties and the risk if adequate control measures are not in place. 

    UNIT STANDARD CCFO CONTRIBUTING 
    Learners are able to act as a responsible citizen in understanding the concept and impact of fraud on the healthcare system. 

    UNIT STANDARD ASSESSOR CRITERIA 
    N/A 

    REREGISTRATION HISTORY 
    As per the SAQA Board decision/s at that time, this unit standard was Reregistered in 2012; 2015. 

    UNIT STANDARD NOTES 
    N/A 

    QUALIFICATIONS UTILISING THIS UNIT STANDARD: 
      ID QUALIFICATION TITLE PRE-2009 NQF LEVEL NQF LEVEL STATUS END DATE PRIMARY OR DELEGATED QA FUNCTIONARY
    Core  49356   Further Education and Training Certificate: Medical Claims Assessing  Level 4  NQF Level 04  Reregistered  2023-06-30  INSETA 
    Elective  49649   Further Education and Training Certificate: Long-term Insurance  Level 4  NQF Level 04  Reregistered  2023-06-30  INSETA 
    Elective  57613   Further Education and Training Certificate: Short-Term Risk Management  Level 4  NQF Level 04  Passed the End Date -
    Status was "Reregistered" 
    2012-06-30  INSETA 
    Elective  66613   Further Education and Training Certificate: Wealth Management  Level 4  NQF Level 04  Reregistered  2021-06-30  As per Learning Programmes recorded against this Qual 


    PROVIDERS CURRENTLY ACCREDITED TO OFFER THIS UNIT STANDARD: 
    This information shows the current accreditations (i.e. those not past their accreditation end dates), and is the most complete record available to SAQA as of today. Some Primary or Delegated Quality Assurance Functionaries have a lag in their recording systems for provider accreditation, in turn leading to a lag in notifying SAQA of all the providers that they have accredited to offer qualifications and unit standards, as well as any extensions to accreditation end dates. The relevant Primary or Delegated Quality Assurance Functionary should be notified if a record appears to be missing from here.
     
    1. African Resources & Financial Training (Pty) Ltd 
    2. ALCARI 233 CC T/A ALCARI (Eversdal)(TP) 
    3. CKP Development Agency (Pty) Ltd. 
    4. De Vries Management & Training Services cc 
    5. DSBI (Pty) Ltd 
    6. Duxah (Pty) Ltd 
    7. Faisit (Pty) Ltd 
    8. Intec College 
    9. Invuya Institute of Learning (Pty) Ltd 
    10. Masifunde Training Centre (Pty) Ltd 
    11. Old Mutual Life Assurance Company South Africa 
    12. Ray Strodl Consulting (Pty) Ltd 
    13. RJM Educational Consulting PTY LTD 
    14. Sanlam Life Insurance Ltd 
    15. Sanlam Life Insurance Ltd. 
    16. The Institute of Health Risk Managers (Pty) Ltd 



    All qualifications and part qualifications registered on the National Qualifications Framework are public property. Thus the only payment that can be made for them is for service and reproduction. It is illegal to sell this material for profit. If the material is reproduced or quoted, the South African Qualifications Authority (SAQA) should be acknowledged as the source.