Belgium
In Belgium EHFCN has several members:
- The Social Information and Investigation Service (SIIS)
- The Control Office of the Mutual Health Funds and the National Unions Mutual Health Funds (CDZ/OCM)
- The National Institute for Health and Disability Insurance (NIHDI)
- The Intermutualistic College (CIN/NIC)
- The Federal Public Service Health, Food chain safety and environment
The Social Information and Investigation Service (SIIS)
Service d’information et de recherche sociale (SIRS) | Sociale inlichtingen-en opsporingsdienst (SIOD)
The Social Information and Investigation Service (SIIS) is a strategic organization which develops a vision on the fight against social fraud, based on the knowledge and skills of the various (inspection) services involved in the fight against social fraud and with scientific support. Subsequently this vision is translated into concrete strategies and operationalized through a biannual Action Plan on fighting social Fraud. In this way, the SIIS also contributes to the execution of the Action Plan of the Federal College for Combating Fiscal and Social Fraud.
| Priority | Action Areas | Category | Example |
|---|---|---|---|
| 1 | Prevention | Compliance to regulations | Both soft and hard |
| 2 | Detection | Compliance to regulations | Data access, legal aspects, tools, .. |
| 3 | Action | Compliance to regulations | All types of action once fraud is detected |
| 4 | Financial Check | Avoid waste/overconsumption | Overly expensive services |
| 5 | Medical Check | Avoid waste/overconsumption | Overutilization of services – no medical evidence |
The National Institute for Health and Disability Insurance (NIHDI)
Institut national d’assurance maladie-invalidité (INAMI) | Rijksinstituut voor ziekte-en invaliditeitsverzekering (RIZIV)
The National Institute for Health and Disability Insurance (NIHDI) organises and financially manages healthcare insurance in Belgium.
The Medical Evaluation and Inspection Department (MEID) of NIHDI oversees the optimal use of financial resources in the health sector. On the one hand, the compliant follow-up of regulations and, on the other hand, appropriate care based on available scientific knowledge. Actions to create behavioural change range from prevention, education, sensitisation, advice for the adaptation of unclear regulations, recoveries, administrative sanctions and the creation of indicators for appropriate care.
The Administrative Inspection Department (AID) monitors the accessibility of care for every insured person. The AID does this by monitoring correct payment and optimal use of funds by the insurance institutions and they combat social fraud by the insured. Therefore they have defined different types of actions in the field of sickness benefits and healthcare (detection, invoicing, sanctions, etc.) .
The following are the five most important areas of healthcare fraud, corruption, and waste, ranked in order of importance according to the NIHDI. This ranking reflects not only the institution’s priorities by choice but also its scope of authority.
| Priority | Action Areas | Category | Example |
|---|---|---|---|
| 1 | Prevention | Compliance to regulations | Both soft and hard |
| 2 | Medical Check | Avoid waste/overconsumption | Overutilization of services – no medical evidence |
| 3 | Financial Check | Avoid waste/overconsumption | Overly expensive services |
| 4 | Detection | Compliance to regulations | Data access, legal aspects, tools, .. |
| 5 | Action | Compliance to regulations | All types of action once fraud is detected |
The Intermutualistic College (CIN/NIC)
Collège intermutualiste national (CIN) | Nationaal intermutualistisch college (NIC)
The Intermutualistic College is an organisation in which all Belgian Health Insurance Funds are represented. The most important role of a Health Insurance 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 costs of their members for all types of healthcare providers, and paying benefits in case of an incapacity to continue working as a contracted labourer, employee, or self-employed person. These expenses are funded by the federal state. Health Insurance Funds must provide detailed information to the federal administration in order to justify their expenses. Health Insurance Funds are paid an agreed fee by the federal state to perform these tasks.
In addition to these important tasks, every Health Insurance Fund provides a variety of services and benefits, for which the Health Insurance Funds charges a membership fee.
All Belgian citizens must become member of a Health Insurance Fund of their own choice, or by default will automatically become member of a Health Insurance Fund service provided by the government. Because Health Insurance Funds have mutual interests, face the same problems and challenges, it is only logical they should consult and cooperate with each other on different levels. The National Intermutualistic College is the highest level of consultation and cooperation between the Belgian Health Insurance Funds.
| Priority | Action Areas | Category | Example |
|---|---|---|---|
| 1 | Prevention | Compliance to regulations | Both soft and hard |
| 2 | Detection | Compliance to regulations | Data access, legal aspects, tools, .. |
| 3 | Medical Check | Avoid waste/overconsumption | Overutilization of services – no medical evidence |
| 4 | Financial Check | Avoid waste/overconsumption | Overly expensive services |
| 5 | Action | Compliance to regulations | All types of action once fraud is detected |
Federal public service Health, Food chain safety and environment
Service Publique Fédéral Santé Publique | Federale Overheidsdienst Volksgezondheid
Federal health care related competences : We organize health care in Belgium. Our areas of expertise include, among others, hospital financing, health care policy and emergency medical aid co-ordination. This page will be updated shortly.
| Priority | Action Areas | Category | Example |
|---|---|---|---|
| 1 | Detection | Compliance to regulations | Data access, legal aspects, tools, .. |
| 2 | Action | Compliance to regulations | All types of action once fraud is detected |
| 3 | Prevention | Compliance to regulations | Both soft and hard |
| 4 | Medical Check | Avoid waste/overconsumption | Overutilization of services – no medical evidence |
| 5 | Financial Check | Avoid waste/overconsumption | Overly expensive services |
The Control Office of the Mutual Health Funds and the National Unions of Mutual Health Funds
Office de contrôle des mutualités (OCM) | Controledienst voor de ziekenfondsen (CDZ)
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 supervision 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.
The Control Office 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 Health and Disability Insurance; four 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 organize one service of complementary insurance in order to intervene financially in favour of their members in the cost for prevention and treatment of sickness and invalidity, or grant 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.
In addition, the Control Office is also the competent authority regarding both prudential supervision and the protection of the insured persons, over insurance companies which have been set up by mutual health funds to offer insurance products. Moreover the Control Office is also one of the supervisory authorities for the specific entities which have been founded to manage healthcare matters transferred from the federal level to the regional level.
| Priority | Action Areas | Category | Example |
|---|---|---|---|
| 1 | Prevention | Compliance to regulations | Both soft and hard |
| 2 | Detection | Compliance to regulations | Data access, legal aspects, tools, .. |
| 3 | Action | Compliance to regulations | All types of action once fraud is detected |
| 4 | Financial Check | Avoid waste/overconsumption | Overly expensive services |
| 5 | Medical Check | Avoid waste/overconsumption | Overutilization of services – no medical evidence |