AHIA Claims Leakage Forum Building Relationships with Ancillary Providers: Clarity, Fairness, Procedure, Compliance Jim Durkin BUPA Australia Health

The Provider Recognition Journey - The Elements PHI & Ancillary Providers The Provider Recognition Journey - The Elements Strong desire as a health fund to enhance the compliance culture ‘What is in the best interests of our customers?’ - Quality, affordable services What expectations do we have regarding provider behaviour? What can and should they expect of and from us? What can we do if we want to end our relationship with a provider?

The Provider Recognition Journey - The Elements (cont.) PHI & Ancillary Providers The Provider Recognition Journey - The Elements (cont.) We introduced a regime of recognising, counselling and de-recognising providers But, terms and procedures in need of review Involvement from Provider & Legal Re-write of ‘Our Ancillary Provider Terms’ Also, ‘What happens if You Breach Our Ancillary Provider Terms’ Accompanying De-recognition and Re-recognition (Yes, re- recognition!) Procedures

Registration and Accreditation of Ancillary Providers PHI & Ancillary Providers Registration and Accreditation of Ancillary Providers Three categories of Ancillary Provider Recognition: - Medicare Australia registered - Providers via Medibank Private - Alternative Therapies Reasonable assumptions re MA & MBP Need to be more explicit regarding our expectations for alternative therapies - insurance, 1st Aid, qualifications Providers mostly referred by Professional Associations Some alternative therapists required specific checks

Registration and Accreditation of Ancillary Providers (cont.) PHI & Ancillary Providers Registration and Accreditation of Ancillary Providers (cont.) Medicare Australia recognised - Dentists, physiotherapists etc OK re: criteria, but still require our Terms Medibank Private recognised - the same Alternative Therapists assumed OK if referred by an Association The ‘$150 check’ Could we be certain about the Association members Formulated Association Accreditation Criteria

Registration and Accreditation of Ancillary Providers (cont.) PHI & Ancillary Providers Registration and Accreditation of Ancillary Providers (cont.) Association Accreditation Questionnaire Documentation - education/quals, Constitution/Charter, Code of Ethics, CPE program etc ‘Undertaking to Comply’ signed by Association rep. Audits conducted by BUPA Australia $150 for non-association members - uncompetitive? Received ‘Immunity from breach’ from the ACCC re: third line forcing All information on the ACCC website, including all Terms etc.

Communication & Education Campaign - The Terms PHI & Ancillary Providers Communication & Education Campaign - The Terms All relevant associations advised of our intention to re-write and distribute these Terms Meetings, discussion, input, advice Markedly different responses depending on the association Established Alternative Therapy Assoc’s eg AACMA, ANTA etc welcomed with open arms ADA - Confused ‘recognition’ with ‘registration’ APA - reasonably supportive and provided input

Some Subjects covered in the Terms How do you agree? What must You do? PHI & Ancillary Providers Some Subjects covered in the Terms How do you agree? What must You do? What must We do? How do we confirm claims are correct? Privacy & Confidentiality When can We end Our relationship with you? How will this happen? What happens if You have committed a breach of the Terms that can be fixed? What happens if you commit a serious breach of these Terms? EG criminal, dangerous Common law damages were always meant to return the injured party to their pre-injury state (as much as money can do this) That is disability to do things, and not just the precise level of impairment

What happens if You Breach Our Ancillary Provider Terms? PHI & Ancillary Providers What happens if You Breach Our Ancillary Provider Terms? Specific document with in-built procedure When will we conduct an investigation? What happens if we believe you have breached the Terms? What if you disagree? What if we need more information? How do we ensure that We make an objective decision? What happens after we have considered your submission? What types of decision can We make? What happens if we commence steps to end Our Relationship? Common law damages were always meant to return the injured party to their pre-injury state (as much as money can do this) That is disability to do things, and not just the precise level of impairment

Where does Counselling fit in the Recognition Process PHI & Ancillary Providers Where does Counselling fit in the Recognition Process Dental issues are complex Issues of concern raised with providers SPP/BPP often point to other issues Specific provider data to Dental Adviser Victoria - Dr Gerry Clausen; South Australia - Dr Peter Clarke

Where does Counselling fit in the Recognition Process (cont.) PHI & Ancillary Providers Where does Counselling fit in the Recognition Process (cont.) Interim reports and counselling recommended (or not) Provider asked to attend counselling and bring records Counselling usually resolves issues (Rules? Glossary? Crowns!) Occasionally behaviour is clearly intentional, therefore de-recognition proceeds Practices and stats improve post-counselling

So, why is everything not entirely perfect? PHI & Ancillary Providers So, why is everything not entirely perfect? We now state that we ‘de-recognise You in accordance with Our Terms’ To be of any use, the Terms have to be in the provider’s possession We have continued to de-recognise providers where a breach is clear and intentional Guild Legal have politely pointed out where Terms not provided We can still seek restitution, remove CPOS etc but…. Forward Terms and start again Currently de-recognised - 5 Optical; 2 Physios; 15 dentists; 7 Alternative Therapists

What are we doing to resolve this? PHI & Ancillary Providers What are we doing to resolve this? Spending the money to distribute to approx. 30,000 providers They will all have the Terms so no excuse We are scouring the Terms to identify and anticipate any changes Already earmarked a clause for ‘sharing information’ Seeking external legal advice on procedures re: other parties and undertakings Eventually e-mail and our Website will take over

Some advantages in Providers having the Terms PHI & Ancillary Providers Some advantages in Providers having the Terms Keeps them honest in their behaviours Keeps us honest in our dealings and treatment If ACCC, PHIO or the media pay us a visit we’re compliant and protect our reputation Provides consistency, clarity, fairness and procedure Once they have them, no excuses Allows us to share information Allows us to confidently de-recognise Formalises the re-recognition process BUPA Australia in 2007 tracking at about 60% of requests on common law matters in 2006

DISCUSSION/QUESTIONS? PHI & Ancillary Providers DISCUSSION/QUESTIONS?