1. AHIA Claims Leakage Forum
Building Relationships with Ancillary Providers: Clarity, Fairness, Procedure, Compliance
Jim Durkin
BUPA Australia Health

2. The Provider Recognition Journey - The Elements
PHI & Ancillary Providers
The Provider Recognition Journey - The Elements
Strong desire as a health fund to enhance the compliance culture
‘What is in the best interests of our customers?’ - Quality, affordable services
What expectations do we have regarding provider behaviour?
What can and should they expect of and from us?
What can we do if we want to end our relationship with a provider?

3. The Provider Recognition Journey - The Elements (cont.)
PHI & Ancillary Providers
The Provider Recognition Journey - The Elements (cont.)
We introduced a regime of recognising, counselling and de-recognising providers
But, terms and procedures in need of review
Involvement from Provider & Legal
Re-write of ‘Our Ancillary Provider Terms’
Also, ‘What happens if You Breach Our Ancillary Provider Terms’
Accompanying De-recognition and Re-recognition (Yes, re- recognition!) Procedures

4. Registration and Accreditation of Ancillary Providers
PHI & Ancillary Providers
Registration and Accreditation of Ancillary Providers
Three categories of Ancillary Provider Recognition:
- Medicare Australia registered
- Providers via Medibank Private
- Alternative Therapies
Reasonable assumptions re MA & MBP
Need to be more explicit regarding our expectations for alternative therapies - insurance, 1st Aid, qualifications
Providers mostly referred by Professional Associations
Some alternative therapists required specific checks

5. Registration and Accreditation of Ancillary Providers (cont.)
PHI & Ancillary Providers
Registration and Accreditation of Ancillary Providers (cont.)
Medicare Australia recognised - Dentists, physiotherapists etc OK re: criteria, but still require our Terms
Medibank Private recognised - the same
Alternative Therapists assumed OK if referred by an Association
The ‘$150 check’
Could we be certain about the Association members
Formulated Association Accreditation Criteria

6. Registration and Accreditation of Ancillary Providers (cont.)
PHI & Ancillary Providers
Registration and Accreditation of Ancillary Providers (cont.)
Association Accreditation Questionnaire
Documentation - education/quals, Constitution/Charter, Code of Ethics, CPE program etc
‘Undertaking to Comply’ signed by Association rep.
Audits conducted by BUPA Australia
$150 for non-association members - uncompetitive?
Received ‘Immunity from breach’ from the ACCC re: third line forcing
All information on the ACCC website, including all Terms etc.

7. Communication & Education Campaign - The Terms
PHI & Ancillary Providers
Communication & Education Campaign - The Terms
All relevant associations advised of our intention to re-write and distribute these Terms
Meetings, discussion, input, advice
Markedly different responses depending on the association
Established Alternative Therapy Assoc’s eg AACMA, ANTA etc welcomed with open arms
ADA - Confused ‘recognition’ with ‘registration’
APA - reasonably supportive and provided input

8. Some Subjects covered in the Terms How do you agree? What must You do?
PHI & Ancillary Providers
Some Subjects covered in the Terms
How do you agree?
What must You do?
What must We do?
How do we confirm claims are correct?
Privacy & Confidentiality
When can We end Our relationship with you?
How will this happen?
What happens if You have committed a breach of the Terms that can be fixed?
What happens if you commit a serious breach of these Terms? EG criminal, dangerous
Common law damages were always meant to return the injured party to their pre-injury state (as much as money can do this)
That is disability to do things, and not just the precise level of impairment

9. What happens if You Breach Our Ancillary Provider Terms?
PHI & Ancillary Providers
What happens if You Breach Our Ancillary Provider Terms?
Specific document with in-built procedure
When will we conduct an investigation?
What happens if we believe you have breached the Terms?
What if you disagree?
What if we need more information?
How do we ensure that We make an objective decision?
What happens after we have considered your submission?
What types of decision can We make?
What happens if we commence steps to end Our Relationship?
Common law damages were always meant to return the injured party to their pre-injury state (as much as money can do this)
That is disability to do things, and not just the precise level of impairment

10. Where does Counselling fit in the Recognition Process
PHI & Ancillary Providers
Where does Counselling fit in the Recognition Process
Dental issues are complex
Issues of concern raised with providers
SPP/BPP often point to other issues
Specific provider data to Dental Adviser
Victoria - Dr Gerry Clausen; South Australia - Dr Peter Clarke

11. Where does Counselling fit in the Recognition Process (cont.)
PHI & Ancillary Providers
Where does Counselling fit in the Recognition Process (cont.)
Interim reports and counselling recommended (or not)
Provider asked to attend counselling and bring records
Counselling usually resolves issues (Rules? Glossary? Crowns!)
Occasionally behaviour is clearly intentional, therefore de-recognition proceeds
Practices and stats improve post-counselling

12. So, why is everything not entirely perfect?
PHI & Ancillary Providers
So, why is everything not entirely perfect?
We now state that we ‘de-recognise You in accordance with Our Terms’
To be of any use, the Terms have to be in the provider’s possession
We have continued to de-recognise providers where a breach is clear and intentional
Guild Legal have politely pointed out where Terms not provided
We can still seek restitution, remove CPOS etc but….
Forward Terms and start again
Currently de-recognised - 5 Optical; 2 Physios; 15 dentists; 7 Alternative Therapists

13. What are we doing to resolve this?
PHI & Ancillary Providers
What are we doing to resolve this?
Spending the money to distribute to approx. 30,000 providers
They will all have the Terms so no excuse
We are scouring the Terms to identify and anticipate any changes
Already earmarked a clause for ‘sharing information’
Seeking external legal advice on procedures re: other parties and undertakings
Eventually and our Website will take over

14. Some advantages in Providers having the Terms
PHI & Ancillary Providers
Some advantages in Providers having the Terms
Keeps them honest in their behaviours
Keeps us honest in our dealings and treatment
If ACCC, PHIO or the media pay us a visit we’re compliant and protect our reputation
Provides consistency, clarity, fairness and procedure
Once they have them, no excuses
Allows us to share information
Allows us to confidently de-recognise
Formalises the re-recognition process
BUPA Australia in 2007 tracking at about 60% of requests on common law matters in 2006

15. DISCUSSION/QUESTIONS?
PHI & Ancillary Providers
DISCUSSION/QUESTIONS?