1. The Member Review Process
AHIA Annual Conference,
July 2008
presented by Neil Angus
Partner, Jeffrey Thomas & Partners

2. Purpose
To outline the member review process as used in the health insurance industry so that you can be aware of another tool that is available to use in managing benefits outlays.

3. Overview Background Objectives Process Results Member Feedback
Benefits
Summary
Questions

4. Background Level of benefits payments at record levels
Level of fraud also at record levels
Funds have to be innovative and “fight back”
Pressure on organisation “bottom line”

5. Objectives To enhance the ancillary benefits management process
To change the providers’ claiming behaviour
To identify fraud
To gather evidence regarding overpayments
To be proactive in the claims area

6. Process Provider Selection:
Benefits payment data is analysed by the fund
Providers are selected for review
may be for a range of reasons
“unusual” level of claims
outside the “normal” range of payments
member complaint
industry “intelligence”

7. Process cont’d Fund writes to provider advising of audit
Required data fields are extracted
Data forwarded to JTP
Member letters and schedules are prepared and despatched
Replies are received and filed
Telephone calls are received and answered
Report is prepared and file returned to client

8. Results Average response rate over 85%
Informative feedback, both quantitative and qualitative
Provided evidence for further investigation and/or recovery
Changed provider behaviour
Informed members and providers that someone is “watching”

9. Member Feedback - Negative
“ I thought the bill was grossly overpriced & have no intention of using this dentist again.”
“… I was not happy with the ‘quality’ of service. The filling came off in a few days.”
“This dentist should be closed down. … he recommended work that was not necessary. This was found out after going to another dentist.”
“I did not receive any of this treatment noted above.”
“I can recall visiting this dentist on one occasion and not two.”
“… I feel not very happy with the services.”
“So yes I think there is something dodgy with this dentist.”

10. Member Feedback - Negative
“The owner is kindly advising about the buying of sunglasses without paying any money as a member … and sometimes some customer are present a glasses to their friend (sic) without paying any money … this kind of business is unfair and to be punished quickly (sic).”
“Two of the services listed were for another person.”
“… what I consider to be the worst case of over servicing that I have come across.”
“I was very traumatised by the experience … I feel most concerned about this man’s ethical conduct.” (chiropractor)
“The services noted were not conducted.”
“I have never seen or heard of … (provider).”
“I have not attended this dentist.”
“when I first went to the dental surgery I thought the place looked somehow dodgy.”

11. Member Feedback - Positive
“I believe Dr xxx to be a very good and caring Dental Surgeon.”
“Best dentist I have ever been to … this chap was very caring.”
“Mr xxx is an outstanding physiotherapist. He has cured a chronic back condition of mine.”
“… very happy with the service of the provider.”

12. Member Feedback - Process
“… I am pleased you keep a check of over servicing.”
One member noted that she was “… extremely glad that these audits are being carried out …”.
“We didn’t realise that we could complain, and we are very pleased that there is an investigation being done.”
“… and now your enquiry presents an opportunity to reveal my concern.”
“It is good to see audits protecting (health fund)”.
“Thank you for your auditor’s check.”
“Pleased to see that this is being done.”
“Thank you for selecting me to take part in your audit and giving me a chance to confirm the selected claims that were paid out to me.”

13. Benefits Some of the benefits to an organisation are:
Important part of benefits management process
Provides evidence for further action
Gathers information/feedback directly from members
Acts as a deterrent to fraudulent providers/members

14. Summary
An opportunity for funds to tap into their largest resource, their membership
Proven process
Process can be applied in any claims type environment
Provides direct/measurable benefits to the organisation

15. Questions