1. Hospital Leakage Presentation to the AHIA National Conference 2007
Mr Keith Joyce
Benefits Risk Manager
Medibank Private

2. What to Look For? Hospital Claims Process Data, Forms, Member info,
Overpayment PHI – staff training, product,
Voluntary Recoveries – learnings, behaviour,
E - environment

3. Hospitals
Data: trends i.e. episodic where cost weight of 1moves dramatically in total, within specialties, between similar profiled Providers, etc
Per diems: treatment profiles trendline around price sensitive touch points
ICU: when paid separately, charges are in line with fund rules.
Admissions: valid or not? ie. 4 hour admits

4. Day Seps

5. The Statistics Benefit Risk Management has an ROI of: 8:1
Where: Area ROI
Private Hosp + Prosth $b2.3 Say 1% = $m23
Public Hosp $m120 Say 4% = $m4.8
Doctors $m300 (Public only) Say .3% = $m1
Ancillary $m700 Say 2.5% =$m17.5

6. Public
IFC Aust sample suggests approx 6% do not receive appropriate/adequate IFC. Some States / Some Hospitals are into double digits
Focus on returns!
(Push by Publics to maximise PHI income stream)
Pte vs Shared bed days – proportion of that billed vs other sites/averages
** to contract or not to contract???** -
The value proposition vs control of outlays/coding/quality/leverage with Private groups?

7. Private patient/Public Hospital

8. Prosthetics Faulty appliances:
How: Data/ DRG’s/appliance/averages/manufacturer
Creates additional: procedures/risks
billings
Warranty breaches/action against manufacturer
Advocate for member re rights, comp,

9. Day Hospitals
Common Features: i.e. ownership structure similar to ancillary
Generally Doctor owned
Services defined
How:
Data sort into high benefit outlay services
Compare to peers for service, other demographics i.e. age, services billed

10. Case Study: Ambulance
Ambulance; Pilot reflected a potential of full year savings of approx $m1 How? Test theory in a sampled environment Quantify result & extend to support a business case Operationalise process + Comms
Results include recoveries, rejections and ability to alter behaviour/partner organisations/contract etc (Pensioner status, travel home, frequent flyers, subs paid elsewhere, medically required that is the question, Rural vic, Hospital to Hosptal.)
Other: improved data base, linkeages with patient transport bodies, members

11. Summary Lots to do/little resource/focus on dollars rather
“The Struggle”
Lots to do/little resource/focus on dollars rather
that the wider good/where is R&D time & $’s/
benchmarking –not relevant/
what is best practice/
hit them hard once/
meeting business demands.