11/11/2018

Investigations Unit Fraud Awareness 11/11/2018

Session Outline About Fraud Types of Fraud Motives Compensation Claims Risk Indicators Community Sourced information Code of Conduct Confidentiality Response to members Emerging areas of risk 11/11/2018

Make false statement with intent to obtain financial advantage What is Fraud? “Telling lies or being dishonest with the intent to obtain a benefit that you are not entitled to.” Make false statement with intent to obtain financial advantage 178BB Crimes Act 40/1900 – NSW 11/11/2018

What’s wrong???? 11/11/2018

What’s Wrong???? 11/11/2018

Why should you be aware of Fraud? Fraud accounts for nearly 20% of all reported crime in this country; OR 5.8 Billion Dollars Around 10% of all general insurance claims are estimated to be fraudulent (ICA) - Insurance Council of Australia - Industry estimates of PHI fraud are believed to be between 1-3% but there are no accurate figures 11/11/2018

Why commit Fraud? Fraud is seen as an attractive alternative to other types of crimes. The reasons include: Socially Acceptable Perceived Entitlement Cheap Little Risk of Detection Non-Violent 11/11/2018

Health Insurance Fraud Different types of fraud within the Health Insurance industry: Hospital, Ancillary, Medical benefits Contribution Staff 11/11/2018

Hospital Hospital Fraud Upcoding Extra nights of stay claimed Overcharging for prostheses (not implanted) Claiming for services for which they are not entitled Outreach services not performed, (no physical attendance) 11/11/2018

Ancillary Ancillary Fraud Limit surfing Falsifying treatment documents Falsifying account documents Over servicing Padding Collusion between Provider and Member 11/11/2018

Medical Medical Fraud Incorrect use of item numbers Collusion with provider Incorrect Invoicing Treatment outside period of cover False claims 11/11/2018

Contribution Making claims knowing that contribution payments will be dishonored (direct debit, cheque, credit card) Receiving 30% rebate knowing contribution payments will be dishonored. 11/11/2018

Compensation Claims Should any information be obtained from members or other sources in relation to compensation matters being pursued by a member, this information should be relayed to the Investigations Department for follow up by our contractors. Our contractors are: National Health Recovery Agents - Mark Hall For Debt recovery: Newcomen Commercial Services - Ron Stephenson 11/11/2018

Staff Making claims on receipts that are not official (made by the staff member). Collusion with friends/family members/providers. Changing bank account details on memberships so direct credit claims benefits will be deposited into their own account. Knowing a staff member is committing fraud and not doing anything about it. 11/11/2018

Risk Indicators Indicators for suspicious claims, sometimes known as “fraud indicators” include: Photocopied receipts Members statements Phone calls where member is being prompted by another person during the claims process Members acting suspiciously during claiming Member not willing to sign documents Never bringing a card with them Always reaching $300 cash limit when claiming 11/11/2018

Risk Indicators – Ancillary Multiple people having same service / same day Amount Charged the same as Benefit Paid Limit surfing ie., using the limits of all dependants on membership 11/11/2018

Risk Indicators – Hospital Item numbers different to service provided Item numbers not matched between hospital and specialist Patients records don’t match care claimed (ICU) Neonatal care claimed for well baby 11/11/2018

Risk Indicators – Medical Overcharging Service not carried out Double charging – submitting the same account more than once Changing item numbers so members can claim (level of cover) 11/11/2018

Community Sourced Information What is Community Sourced Information? This is information which has been provided by persons alleging a suspicious event that has, may, or will occur People provide us with information freely and we use it to assist us for investigation purposes. Sarbanes-Oxley Act 2002 requires effective complaint management 11/11/2018

Community Sourced Information Why we receive Community Sourced Information Their conscience compels them Concern regarding the cost to the community and rising insurance premiums Annoyed with a person/s boasting Seeking revenge towards another person, vexatious complaint i.e. competitors Giving the information as general interest without knowing it’s usefulness and/or relevance 11/11/2018

Community Sourced Information A Fraud Hotline has been established to take community sourced information nationally for NIB. 9am – 5pm (EST) Monday – Friday 1800 663 223 11/11/2018

Community Sourced Information The email address for information is investigations@nib.com.au Any documents or hand-written notes should be forwarded or faxed to: NIB Investigations Unit Level 2 384 Hunter Street Newcastle 2300 Fax No. 02 4927 2197 11/11/2018

Code of Conduct The NIB Code of Conduct states in part that “...employees must report any unsafe practices or suspected corrupt behavior to their manager / supervisor who will forward the report to the Investigations Department.” 11/11/2018

Confidentiality All information supplied either by NIB staff or community sources is confidential. For further information please read the NIB Confidentiality Agreement published on Insite. 11/11/2018

Standard Response “Your claim has been selected for random review and will be forwarded to head office for processing. This is not meant to cause you any inconvenience and your claim will be processed as quickly as possible.” Should the member or provider have any concerns, they should be referred to the NIB Investigations Unit 1800 663 233 11/11/2018

Emerging Areas of Risk Ecommerce Fraud (online claims lodgments) Identity Fraud Expansion of electronic claiming networks 11/11/2018

In Conclusion Should you identify any areas of risk to the business, please report to your manager or email the NIB Investigations Unit to discuss the matter. Our commitment to you is to respond within 48 hours of your notification of any concerns. We will also keep you updated on the progress and the final result of the information supplied to the Investigations Unit. 11/11/2018

Case Examples Case Example 1. Case Example 2. Chiropractor claiming benefits for services not rendered using the HICAPS facility. Provider profiling and investigation revealed in excess of $28000 in overcharging which was refunded to NIB. Case Example 2. A part time dental receptionist who was also a member of NIB was fabricating false invoices for dental treatment for both her and her husband which were not performed. Police have charged the member with numerous counts of fraud relating to the deception of NIB and other financial establishments. Over $8000 was refunded to NIB by the member. 11/11/2018

Question Time?? 11/11/2018