1. Medical Leakage Jane Boag – Australian Unity Dr Andrew Cottrill – HCF
AHIA
Private Health Insurance:
Claims Leakage and Fraud Forum

2. Medical Relating to the science or practice of medicine
An examination to assess a person’s physical health
*Oxford Dictionary

3. Leakage
Accidentally allow contents to escape or enter through a hole or crack
Intentionally disclose (secret information)
*Oxford Dictionary

4. Medical Leakage Medical costs that slip through the cracks
An area that has traditionally lacked attention
Experiences are limited

5. Spectrum of Leakage
Best
Practice
Fraud
Inefficient
Practice

6. Framework to Approach Leakage
Norms
Standards
Patterns
Comparing Drs against their peer group.
Comparing practice against generally accepted approach or agreed guidelines.
Evidence based medicine
Finding hidden associations and relationships in our data

7. Methods Norms Standards Patterns Outlier analysis.
Traditional statistics
Information sharing
Rules based systems
Peer review
Data mapping tools.
Data mining tools.
Neural networks.

8. Problems Norms Standards Patterns
Easy to do but difficult to account for practice differences and casemix.
The “norm” may not be the most efficient way.
Poor agreement on standards.
PHI data poor quality to build clinical rules.
Software rules can be difficult to build and maintain.
Associations may not provide sufficient “proof” to intervene.
Tools difficult to use and results hard to interpret.

9. Examples Norms Standards Patterns
Hospital benchmark reports – concept can be applied to doctors.
ICU claims review
Dr Hospital mismatch report
Dr gap scheme compliance audits
Associations between prosthesis item and CMBS codes

10. Model for Claims Leakage
Apply
Rule Set
MOST OK
Claim
Payment
Claim
Capture
Few
Flagged
Learning
Manual
Investigation
Build Rule
Set
Data Mining
Tools
Data
Warehouse
Learning
Profiles

11. Medical Leakage Practical Issues

12. Where do we go if we have an issue with a medical practitioner?
Relevant health complaints bodies
Relevant state practice bodies
Eg. in Victoria – Health Insurance Commission. They meet regularly with the Medical Practitioner Board of Victoria to determine jurisdiction on complaints. Anything that is about the professional conduct of the practitioner is the responsibility of the Board. All states and territories have similar bodies. These complaints may also overlap with civil or criminal court proceedings. Most of the case studies highlighted later in the presentation are from medical practice boards.
Medical Practitioners Board of Victoria – there to protect the community and support the profession

13. What makes medical different to hospital and ancillary?
Status of the medical profession
Implied trust
Are billing issues more difficult if related to hospital admissions?
Most issues are raised from consumers about professional conduct.
Do private health insurers have a responsibility to question medical professional conduct more than they do?
Do private health insurers raise concerns as often with medical practitioners as they do with ancillary or hospital providers – if not, why not?

14. What is the impact on private health insurers?
Increased claims cost
Mitigation costs, including system development
How do we really know what the cost is?
Has anyone done a ‘leakage’ review of medical claims?
Are systems development re: straight through processing and/or data mining focused on medical claims?

15. Identity Fraud Falsification of: personal identify
qualifications &/or experience
Identify fraud –
The Age 17/8/07 – Dr Mohammed Ali Australia – “revealed that he had faked 3 months employment history on resume”. 13/8/07 – “owning rubber stamps that could be used to forge medical testimonials”
Questions –
Could this happen in the private health insurance market?
What steps do we have in place to check identity and qualifications?
What relationship do we have with registration boards and representative bodies?
What would happen if we found ourselves in this situation?

16. Case Study Dr Ali ‘Doctored’ resume Variety of name stamps
Identify fraud –
The Age 17/8/07 – Dr Mohammed Ali Australia – “revealed that he had faked 3 months employment history on resume”. 13/8/07 – “owning rubber stamps that could be used to forge medical testimonials”
Outcome – suspended from job, left country, 457 visa dependent on job with QLD Health
Questions –
Could this happen in the private health insurance market?
What steps do we have in place to check identity and qualifications?
What relationship do we have with registration boards and representative bodies to check identify and qualifications?
What would happen if we found ourselves in this situation?

17. Case Studies Mr D Sports medicine qualifications
Worked as General Practitioner in his brother’s practice for 6 years
Complaint made by consumers – suspected that he didn’t have qualifications
Illegal action supported by Dr brother
Outcome – registration cancelled
Questions-
Who is in the wrong?
How did it continue for so long?
How would private health insurers respond?

18. Misuse of authority Prescriptions Permits Medical certificates/reports
Medical record keeping
Medical Practitioner Board of Victoria very clear about these are key focus areas in maintaining professionalism & also privacy – spend a lot of time reminding medicos about this.
Same issue that potentially impact on private health insurance claims leakage.
Questions –
how often does the backdating or medical certificates occur?
How many times do you suspect that medical reports are false?
What steps do we take to review these practices?

19. Case Study Dr K Self prescribing schedule 8 medications
Outcome – deregistered several times – moved to job where registration not required
Questions-
Are thefts always reported?
Or, what about the doctor’s that knowingly prescribe for patients who are also getting medications from another practitioner?
Are doctor’s compliant with permit applications, etc?
What about doctors who treat family and friends?

20. Case Study
Dr K
Knowingly provided incorrect information on medical certificates to overseas students
Questions
How often does this sort of thing happen?
What cost might it have for private health insurance, especially relating to pre existing ailment assessments?

21. Poor billing practice Matching medical fees to hospital admissions
Accurate records relating to billing
Potential for double dipping
Questions -
What processes you you have to match medical and hospital charges?
What is the impact of electronic billing (EDI & EPM contracts)?
What about shared practice groups, shared reception staff, etc?
Can people claim via medicare, private health insurers, DVA, workers comp, third party insurers, etc

22. Over servicing Referral chains Unnecessary procedures
Reliant on patients and peers for feedback
will data mining and trend analysis be enough – Russian car crash example

23. Barriers to Success Ever changing environment
Blurring of medical practitioner roles
Cost and complexity of mitigation strategies
Reliant on patients and peers for feedback
Impact of legislative change, skills shortage, rural shortage, lifestyle expectations, etc
Emerging and merging professions – nurses, OT’s
How will ageing population impact further?
Is size and scale important re: private health insurers?

24. What next? Monitor Medicare’s compliance plan
Seek process and/or technology solutions
Explore appropriate information exchange
Raise awareness

25. In closing… Thanks for listening! Identify fraud –
The Age 17/8/07 – Dr Mohammed Ali Australia – “revealed that he had faked 3 months employment history on resume”. 13/8/07 – “owning rubber stamps that could be used to forge medical testimonials”
Outcome – suspended from job, left country, 457 visa dependent on job with QLD Health
Questions –
Could this happen in the private health insurance market?
What steps do we have in place to check identity and qualifications?
What relationship do we have with registration boards and representative bodies to check identify and qualifications?
What would happen if we found ourselves in this situation?