Ancillary Benefits Leakage – What to Look For

Wine Appreciation 101

This goes with that, goes with this, goes with that…

Week 1 Main Courses: Oven roasted Snapper fillet with Tuscan bread salad and Yarra Valley salmon pearl aioli Accompanied by ‘05’ Roche Premium Sauvignon Blanc Beef tenderloin and pancetta with velvet potato puree and sautéed forest mushroom Accompanied by ‘03’ Roche Premium IJR Shiraz Slow roasted pork with chat potatoes, rosemary & garlic Accompanied by ‘04’ Roche Premium WR Merlot

Ancillary Benefits Leakage – Issues Commonly Identified

Issues Commonly Identified Upcoding Bill padding Claiming across multiple people on a membership Claiming across benefit years Splitting cost across multiple dates of service Using another provider’s number Altering receipts .

Upcoding Common in dental claims Easy to get away with as members don’t understand dental item codes or what services they have received Used often in restorations such as Billing for 3, 4 or 5 surface filling items (513-515, 523-525, 533-535, 543-545, 553-555 ) instead of 1 or 2 surface (511-512, 521-522, 531-532, 541-542, 551-552) Billing for indirect restorations (541-555) instead of direct restorations (511-535)

Bill Padding Common in dental but also in optical Dental – Xrays on every consultation (022) Fluoride on every consultation (121) Oral hygiene instruction for every patient (141) Fissure sealing for every child patient and even some adults against clinical indications (161) Cusp capping (577) on majority of front teeth restorations and Incisal corners on back teeth restorations (578)

Bill Padding continued… Optical – Additional charges added to bill for lens coatings including: Hard coatings UV coatings Scratch resistant coatings When most of these add ons are now intrinsic in lens design and manufacture

Claiming across multiple family members When the limit for one person is reached they claim against another family member or person on same membership; or Splitting cost across two members to get maximum claim rebate eg. glasses costing $300 split across husband and wife @ $150 each to get full rebate.

Claiming across benefit years Very common across December/January and June/July when funds benefit years roll over. Cost is often split to claim part in one benefit year and the remainder in the adjoining benefit year. Example: member having a number of veneer services (582) and reached limit so remaining services actually performed on 29 June claimed on 2 July in new benefit year.

Splitting cost across multiple DOS To increase the benefit amount rebated to a member and eliminate out of pockets the service cost is split across multiple dates of service Example: remedial massage service with a cost of $45 performed on 3 June split into 3 services across 1, 2 and 3 June at $15 per service.

Using another provider’s number Often used in multi provider practices when some of the providers do not have appropriate qualifications. Use the provider number and name of a provider who is recognised by funds. Have one receipt with only the one provider name and details. Example: a massage outlet with several massage providers using the provider number of a recognised acupuncturist and charging all services as acupuncture performed by the recognised acupuncture provider

Altering Receipts This if more often done by a member than provider in order to obtain a benefit when limit reached, to increase rebate, claim from an unrecognised provider or claim for a service not even provided. Examples: Changing date of service Changing name of patient Changing amount charged Changing name of provider Duplicating another receipt