Group Loss Prevention Awareness Wayne Stone Manager Group Loss Prevention Awareness HBF Insurance

Case studies.. Provider Fraud Employee Fraud Member Fraud

Amidi-Mazaheri – Dentist 2004 Concern received through fraud hotline relating to: Over servicing Padded claims Poor clinical treatment

Initial Enquiries In practice with girlfriend & dentist Mogjan Azari and had recently opened private practice to supplement NHS work. Was ‘flash with cash’ and had recently spent almost $200,000 on a new car. No history of Amidi-Mazaheri could be found in Iranian dental training colleges. Highlight deal with wrongful activity first as this is what is within the policies.

Review 600 patients participated in clinical reviews to determine validity of claims:- Many of services items claimed had not been performed Those that had been performed were of very poor standard Tales of: Major procedures completed without injection Inability to stem bleeding Dental tool being dropped down throat of patient.

Action Mazaheri & Azari arrested & interviewed Admissions: Padding & falsification of claims to value of $250,000 Mazaheri not qualified to practice Had assumed identity of dead dentist with similar name Failed asylum seeker Azari had allowed him to gain experience practising on her patients

Sanction Mazaheri – Sentenced to 2 years imprisonment Azari – Sentenced to 12 mths imprisonment De-registered by General Dental Council Civil action led to recovery of in excess of $200,000

Things to consider? Consider the bigger picture Don’t always assume others have done their job! Be prepared to raise concerns with professional bodies Review internal registration procedures

Employee Fraud ! March 2005 Anomaly identified with health service claim on recently cancelled policy Initial enquiries: Provider denied providing service Member denied submitting claim.

Employee Fraud ! Video footage confirmed processing employee Subsequent analysis of policies confirmed: 73 claims processed against cancelled policies in previous 12 months Cash paid in excess of $30,000

Evidence Member pro forma’s developed to confirm / deny legitimacy of claims Based upon initial responses evidential fraud package relating to 18 offences passed to police

Action Employee arrested at home address Interviewed and fully admitted and later charged with 61 offences – Theft servant July 2005 received: 18 mth suspended prison sentence 12 mth supervision order 150 hours community service Continues to repay monies

Things to consider Don’t always think external! Know your systems and their weaknesses Run analysis to target those weaknesses Promote a zero tolerance culture Be prepared to produce a package of evidence

Member Fraud April 2006 Concern through fraud referral process following receipt of dental account where service cost was below HBF tariff. Analysis showed further similar claims relating to same member and provider

Enquiries New policy PO Box address Provider had no record of treating member Accounts provided were not in providers format Attempts to contact member were rebuffed Evidential package prepared for police

Action Member arrested and fully admitted submission of false claims Decision taken by police to caution due to illness….. Decision taken to charge due to previous Medicare fraud Fined $500 Repaid all monies Declared unacceptable member

Things to consider Ease of obtaining medical insurance Benefits far outweigh premiums Analysis needs to consider all things out of ordinary Adopt a zero tolerance culture

Themes All referred through fraud/concern processes All had issues not readily apparent In all cases financial restitution was sought & obtained In all cases zero tolerance was shown