1. HICAPS Transactions and Usage Reports
AHIA Private Health Insurance
Claims leakage and Fraud Forum July, 2008
Chris Williams and Brett Butler

2. Roles …….
HICAPS is not in a position to detect provider or patient fraud as our role within the e-claim process is to act as the ‘switch’ – i.e. we transmit data between the provider & the health fund
We do however have an obligation to work closely with our partner funds to assist them in the management of their ancillary claims fraud risk.

3. HICAPS Transactions and Usage Reports
HICAPS has a variety of tools that can assist you in identifying claiming irregularities
HICAPS reports
“alphabet reports”
HICAPS Accounts Online
Transaction Search Engine
Audit provision in the Provider Agreement

4. HICAPS Reporting

5. The “Alphabet” Reports Daily Reports
HICAPS Reporting
The “Alphabet” Reports
Daily Reports
J – MultiSwipes
K – Management Overview
L – CSS Audit Log
M – Quote Anomalies Report
N – Average Item Charge Discrepancy
O – Invalid Item Number Listing
Monthly Reports
KM Report – Monthly Management Report
NM Report – Monthly Average Item Charge Discrepancy

6. ‘J’ file – Multi-Swipe Report
HICAPS Reporting
‘J’ file – Multi-Swipe Report
Provides a listing of any Terminal that process more than 2 transactions with the same card on the same day.
The report is displayed by Terminal by Card Number by Provider.

7. ‘K’ file – Daily Management Report
HICAPS Reporting
‘K’ file – Daily Management Report
Number of available providers by Modality
Providers currently not available by Modality
New Providers previously suspended by fund
Number of Providers on the Multi Swipe Report
CSS Settlement Value
CSS Transactions Reversals completed by the Fund
Top 20 Providers by Claim Benefit Amount
Claim Line Breakdown by Return Code + Average over the switch
Transactions Breakdown by Return Code + Average over the switch
Invalid Item Numbers
Providers Declined by Fund
Zero Benefit on approved transactions
Benefit paid on a declined transactions
Fund System Inoperative / Timeout

8. ‘KM’ file – Monthly Management Report
HICAPS Reporting
‘KM’ file – Monthly Management Report
Number of available providers by Modality
Providers currently not available by Modality
Number of Transactions Processed
CSS Settlement Value
Number of quotes processed
Top 20 Providers by Claim Benefit Amount
Top 20 Members by Total Claim Benefit Amount
Providers on the Multi Swipe Report 2 or more times
Claim Line Breakdown by Return Code + Average over the switch
Transactions Breakdown by Return Code + Average over the switch
Providers Declined by Fund

9. ‘L’ file – HAO User Audit Report
HICAPS Reporting
‘L’ file – HAO User Audit Report
Contains which Fund users have made changes to the Fund data via the HICAPS Accounts Online System
‘M’ file – Quote Report
Contains Transactions where a quote has been processed within 10 minutes of a claim.

10. ‘N’ Report – Average Item Value Report
HICAPS Reporting
‘N’ Report – Average Item Value Report
The N report is the Daily Average Item Value by Provider Report
Displays the average item value for your fund for a provider compared with the average item value across the HICAPS switch for the same provider.
Aimed at those funds who pay percentage based benefits.
Will be run every day and sent via National Online.
Configurable for each fund
Available upon request

11. ‘NM’ Report – Monthly Average Item Value Report
HICAPS Reporting
‘NM’ Report – Monthly Average Item Value Report
The NM report is the Monthly Average Item Value by Provider Report
Displays the average item value for your fund for a provider compared with the average item value across the HICAPS switch for the same provider.
Aimed at those funds who pay percentage based benefits.
Will be run on the 3rd day of the month and sent via National Online.
Configurable for each fund
Available upon request

12. N and NM Report Configuration
HICAPS Reporting
N and NM Report Configuration
This report is configurable for the following set of values for each fund
Fund accepts or declines to receive the report.
Percentage difference before an item appears on the report
Both Positive and Negative exceptions to the percentage difference.
Positive exceptions only to the percentage difference.
Report Format
Report
Data (Fixed Field Text File)

13. ‘O’ Report – Invalid Item Transactions Report
HICAPS Reporting
‘O’ Report – Invalid Item Transactions Report
This report show where the Fund has returned a item number that is not represented in the industry agreed item schedules.
The Item Number returned does not match the Providers Modality
Exception : If the Fund returns one of the 4 Item Return Codes listed below the transaction will not appear on the report.
10 Invalid Item Number
11 Item Number Ceased
12 Item Not Valid for Provider
43 Transaction Declined – Refer Transaction Response Code
The Item Number returned is valid however the Return Code is a 10 or 11.
Exception : If the fund returns the Item Return Code 12 Item Not Valid for Provider the transaction will not appear on the report.
All Transactions where a Item Return code 10 Invalid Item Number is returned

14. HICAPS Accounts Online
Transaction Search Engine

15. HICAPS Accounts Online
The search criteria can be created from many of the fields in the HICAPS Database.

16. The Display criteria can be created from many of the fields in the HICAPS Database.

17. The View on screen option allows you to have your search data returned to the screen

20. The CSV Download option allows you to have your search data returned to you in a format that can be imported in to a spreadsheet application like Excel.

23. Transaction Search Engine
HICAPS is implementing some changes in the coming months to the transaction search engine .
If you have any suggestions or changes to the search engine that would make your life easier, please let us know.

24. AHIA Fraud Committee Reporting Requests

25. AHIA Fraud Committee Reporting Requests
HICAPS Reporting
AHIA Fraud Committee Reporting Requests
1) Optical Prescriptions- Is there a way that we can collect the optical prescription through the system? If so, what are the restrictions in entering the data (Character length, can it be alpha-numeric, cost)?
2) Patient Cascading Benefits- Can we have a new report that identifies when a claim is rejected as a "04", "05" or "06" and then the claim is reprocessed under a new patient code on the same membership?
The Clinical Code field is a 2 digit numeric field.
To include alpha numeric or/and field length changes will reduce the number of item possible per claim.
This change would have to be made by all participating health fund systems as well as HICAPS terminal software and the HICAPS switch.
Plausible – Effort : Medium

26. HICAPS Reporting
AHIA Fraud Committee Reporting Requests
3) Identical claims processed on the same day- We have a problem that if a dentist processes a claim (for example 011, 022, 022, 531, 532) and thinks for whatever reason that it has not gone through, they process it again. Some Health Fund systems do not register these claims as a duplicate claim. It will stop the (011, 022 and 022) being processed as previously paid but it still pays on the two fillings again (531, 532).
4) Stolen c/c to pay gap. Denise Pope mentioned at times stolen cards are used to pay the gap. How can we tap into this info and develop some synergy? Chances are if they are paying with a stolen c/c, they have either stolen the wallet with our card in it or it is a false identity.
Plausible – Effort : Medium
Not Possible

27. AHIA Fraud Committee Reporting Requests
5) Highest claiming memberships- Is it possible to get a monthly report that identifies our top 10 or 20 claiming memberships (same fund, same client number, sum of benefits paid (irrespective of provider number)?
6) Body Part- I know this has been talked about for years and the issue seems to be with funds agreeing on the identifiers to be used. Can you give us the restrictions around this field (i.e. number of fields available and are they alpha-numeric)
Completed – Included in the Monthly Management Report
The Clinical Code field is a 2 digit numeric field.
To include alpha numeric or/and field length changes will reduce the number of item possible per claim.
This change would have to be made by all participating health fund systems as well as HICAPS terminal software and the HICAPS switch.

28. HICAPS Reporting
AHIA Fraud Committee Reporting Requests
7) Multiple claims same practice- Often there are numerous providers registered at a given practice. Unfortunately a current shortfall (one of the many) of some Health Funds systems is that it can not distinguish groups of claims at the same practice. Is it possible to have a report that identifies groups of claims from the same membership, on the same day, at the same practice but different provider numbers? I was thinking this could be based on the terminal ID. Does a practice ever have more than 1 terminal??
8) Question- How is a provider prevented from taking a terminal from one practice to another. Is the terminal locked to the CLI (Calling Line Indicator) that it uses to call into your system?
Completed – Included in the Multi Swipe Report
Not Possible

29. AHIA Fraud Committee Reporting Requests
HICAPS Reporting
AHIA Fraud Committee Reporting Requests
9) Question- What happens when a HICAPS machine is stolen?
10) Can we have a report that tells us the providers that have exceeded a service limit cap? - The funds (at an industry level) could provide you with an expectable number (for example a physiotherapy consultations should be at least 20min- therefore the service limit would be 3p/hr x 8hrs = 24 a day) I'm not sure how privacy would affect this but the data would only be useful if it could count the total transactions for all funds.
11) Unusual patterns- Is it possible to get similar software to the Falcon program that the banks use for credit cards that identify claims that are outside the norms for that membership? I know I am probably dreaming but it doesn't hurt to ask.
Once the terminal is reported stolen the terminal pin pad keys and terminal configuration are deleted from the HICAPS switch making the terminal inoperable
Plausible – Effort : Intensive
Not Possible

30. AHIA Fraud Committee Reporting Requests
HICAPS Reporting
AHIA Fraud Committee Reporting Requests
12) Multiple practice registrations- Provider can legitimately be registered at numerous practices at any one time. To help us identify the provider numbers that are potentially being abused (someone else is providing the service and claiming under their name), can we have a report that identifies providers (and the claims) that have had two separate claims lodged through HICAPS within an hour at two completely different locations? For example- John Smith might have a practice at 382 George Street Sydney and 14 John Street Bankstown. If he processed a claim at both practices within an hour you would alert us the next day in our report.
An internal report is currently being generated assess this issue but due to multiple terminals at sites the cross reference table needs to be updated before general release.

31. AHIA Fraud Committee Reporting Requests
HICAPS Reporting
AHIA Fraud Committee Reporting Requests
13) Claims processed at impossible intervals. The report would reference claims for all funds and look for providers with claims processed close together on different memberships that would not be possible for the provider to complete the service. For example member 123 for HCF goes to podiatrist 'Baker' at has a claim processed at 10:01am. Then another claim is processed for member 456 from NIB at 10:06am and another for member 789 from Medibank at 10:11am. We (HCF) would not see anything unusual as we cannot see another transaction was processed so close together unless you can provide us with the times that other transactions have gone through. The report may need to be restricted to 3 or more memberships within a short period- Just in case the receptionist is held up by a system fault.
Plausible – Effort : Intensive

32. AHIA Fraud Committee Reporting Requests
HICAPS Reporting
AHIA Fraud Committee Reporting Requests
14) Medicare- Is there the chance that HICAPS will be processing allied health claims for Medicare in the future? If so, can you alert us to claims that have been processed through Medicare and the fund? Legislation strictly prohibits benefits being claimed through Medicare and a health fund for the same service.
15) Monthly count on the times that providers appear in the J report- Is it possible to get a new report at the end of each month that has an aggregate sum of the times that a provider has appeared in the J report in the past month?
Not Possible
Completed – Included in the Monthly Management Report

33. Member Name on the HICAPS receipt

34. Member Name on the HICAPS Receipts
Printing the member name on the terminal receipt
Having the member name would require system changes by both the Funds and HICAPS. This change would also reduce the number of items single transaction could carry.
This item was discussed at the HICAPS User Group meeting where Funds were to confirm that the use inclusion of patient name in the HICAPS message and receipt does not breach any existing agreements.
Many providers have indicated they would support the patient name on the receipt as it makes their reconciliation easier.

35. Other Modalities

36. Other Modalities
HICAPS has been approached by the fraud areas of many Funds to implement Pharmacy.
This item was raised at the HICAPS users group in May and unfortunately the delegates did not support this initiative. The primary reason was that Funds believe that they are processing only a small amount of the potential pharmacy claims
Each fund will need to weigh the business reasons against the risk mitigation benefits to support processing pharmacy transactions electronically.

37. THANK – YOU for the opportunity
Questions & Answers
THANK – YOU
for the opportunity