India drew on its participation in the JLN’s Medical Audits Collaborative and adaptation of the Medical Audit Toolkit to implement a medical audit system that could be decentralized and scaled by India’s states to review claims, identify fraud, and ensure the quality of health services being provided to patients.
Malaysia’s use of the Toolkit to Develop and Strengthen Medical Audit Systems shaped the operations for a new Medical Audit Section responsible for auditing PeKa B40 claims. The SOPs for the unit support identifying and deterring fraud and review of provider perfomance resulting in improved quality of health care screenings. This case study profiles the use of the Toolkit to Develop and Strengthen Medical Audit Systems in Malaysia. In 2019, the Malaysian Ministry of Health (MOH) launched the PeKa B40 scheme, a program designed to increase screening uptake for non-communicable diseases (NCDs) among Malaysians in the lower-income group; specifically the bottom 40% of the population by income level. Through PeKa B40 program, MOH was exposed for the first time to the claims processing. Claims processing in Malaysia was traditionally done by insurance companies in the private sector, but through ProtectHealth, the Ministry is responsible for PeKa B40 claims from both the public and private facilities. This is an opportunity to make the PeKa B40 claims process transparent and accountable. In April 2019, the Ministry established a Medical Audit Section within ProtectHealth to process and audit PeKa B40 claims. The team used the Toolkit to Develop and Strengthen Medical Audit Systems to design the systems for this new unit.
This toolkit was created to address gaps in practical knowledge by providing guidance on setting up medical audit units, a step-by-step review of claims to identify providers prone to fraud or poor quality of care, conduct investigations, and use the results of the medical audit.