1. ALLIED HEALTH INVESTIGATIONS WORKSHOP
What Determines Appropriate Care
Helen Kindness
July 2008

2. How Do Health Funds Define Appropriate and Inappropriate Care?
Client satisfaction?
Clinical Outcomes?
Value for Money?
General Health Outcomes?
Provider Compliance?
Peer Support?
Regulatory Body Support?
Research Based Evidence?

3. Is Claims Leakage and Fraud Linked to Inappropriate Care?
If there is consensus that inappropriate care can be a marker for claims leakage and fraud, how is this identified?
Are there clinical and claiming patterns that can help identify claims leakage and fraud?
What do we look for and how useful is the data / information?

4. What To Look For? Data Mining
Aberrant claiming patterns i.e. unusually high claims for each day or week.
If a practitioner is seeing 30 of your Health Fund’s clients in a day, how many other health fund clients are also being seen on the same day?
Remember that most Providers also treat Workers’ Compensation, CTP, Medicare and DVA clients in addition to their private clients.

5. 8 hours 20 patients = 24 minutes / patient
How Many Patients Do Providers Claim to treat in One Day? What is Considered a Reasonable Treatment Session?
8 hours 20 patients = 24 minutes / patient
8 hours 30 patients = 16 minutes / patient
8 hours 40 patients = 12 minutes / patient
8 hours 50 patients = 9.6 minutes / patient
8 hours 60 patients = 8 minutes / patient
8 hours 70 patients = 6.8 minutes / patient
8 hours 80 patients = 6 minutes / patient
8 hours 90 patients = 5.3 minutes / patient
8 hours 100 patients = 4.8 minutes / patient

6. How many Days / Week do Providers say they work?
The Record so far is for 1 Provider who claimed to treat
80 – 100 patients / day
7 days / week
with 3-5 minute consultations!

7. What Are Currently Acceptable Standards?
Most Respected Allied Health Providers from any discipline will say that they can treat up to a maximum of 40 patients / day if they are pressed, but feel that they offer optimal clinical service if they see between 25 – 30 patients / day

8. What Else Does the Data Tell You?
Multiple family members always attending on the same days of service.
Is this usual clinical practice? NO!
If this is a commonly recurring pattern for a provider should it ring alarm bells? YES!
Can this be considered a marker for possible fraud? YES because it most commonly involves multiple HICAPS swipes for the one treatment session.

9. More Data Information
Average numbers of treatments per episode of care for each patient
If this is high, does it always mean the treatment is inappropriate? NO!
Does it require further investigation? YES!
What would be considered a reasonable number of treatments per episode of care for any Discipline?
3-10 treatments as a very rough guide. More than 15 – 20 treatments for all clients as a regular pattern requires investigation in any allied health discipline.

10. On Site Clinical Audits
All allied health providers from ALL disciplines are required to keep comprehensive clinical records outlining patient examinations, treatments, consent to treatment, precautions, contraindications to treatments, treatment plans, responses to treatment, referrals to other practitioners if appropriate, treatment outcomes, test results, reasons for discharge. The clinical notes need to tell the patient story and their response to treatment. They need to be meaningful to another practitioner.

11. Are Poor or NO Clinical notes are marker for claims leakage and fraud?
Poor clinical notes or no clinical entries at all are very often associated with fraudulent claiming patterns.
Is it enough if the provider can tell you the patient story verbally in the absence of comprehensive clinical notes? NO!
Unfortunately the provider story can be convincingly fabricated to hide fraud.
A provider’s best defence are comprehensive clinical entries for each occasion of service

12. What about Electronic clinical entries?
Unless electronic entries are entered on a system similar to case manager which dates the entries and has identifiers for the person entering the data, the entries can very easily be falsified.
It is NOT appropriate for a third party to enter treatment notes in a client record; electronic or manual.
All computer treatment entries MUST be backed up daily on a device stored away from the main computer to protect against theft or computer failures etc.

13. Some Other Reasons to Investigate a Provider
Evidence of a client receiving 2 treatments from 2 different providers from 2 different disciplines on the same day e.g. Physio and Chiro or Massage and Chiro.
Providers who charge for treatment and also supply and sell treatment aids e.g. podiatrist who provides footwear and orthotics for all patients who attend for treatment.
Complaints from patients

14. When In Doubt…
Review claiming patterns for the same providers over a number of years to detect significant changes
Review HICAPS access. Does this change the claiming pattern significantly?
Ask for treatment plans or clinical notes
Check with relevant consultants, professional associations or registration boards