1. AHIA Claims Leakage & Fraud Forum
HICAPS - Drilling Down
Keith Joyce
Benefits Risk Manager
November Medibank Private

2. Reports Backdate Alerts:
Recover overpayments where transactions are backdated
Body Part alert:
Where item number is invalid in relation to a specific body part
Claims Alert:
A number of alerts to surface claims patterns – to investigate further

3. Reports - cont Crown alert: Claims to teeth that previously crowned
DOS alert:
Where DOS changed to enable benefit payout
Endo alert:
Where D415 & D417 on same tooth i.e. >1
Fill alert:
Multiple restorations same tooth - consecutive visits

4. Reports cont Limit surf:
Potential where services claimed for patient that did not receive service
Mbr travel:
Claims same day, same member, different provider
Multi Mod:
i.e. Providers co-located – cross refer

5. Reports cont No tooth alert: Self explanatory Outlier by item & group:
item level stats where services are x% above peers
Prov Stats:
Provider outliers
Prov switch:
Where prov no. changed to enable payment

6. Reports cont Prov travel:
Claims same provider, same day, different location
Rule alert:
Claims that are mutually exclusive
Run totals:
Summary stats for reporting period
Upcodes:
Claim, then cancelled, claimed higher benefit

7. Conclusion
? Questions