1. Outsourced Leakage Analysis and Investigations
AHIA Fraud Forum August 2007

2. AHIA Fraud Forum August 2007
Background of BJ
Commenced in Year 2000
Goal to combine analytics with audit and investigative skills to provide:
Identification of leakage/fraud
Quantification of cost
Action in accordance with cost
Conduct hundreds of provider audits and investigations per annum
AHIA Fraud Forum August 2007

3. AHIA Fraud Forum August 2007
Market Coverage
AHIA Fraud Forum August 2007

4. Outsourced Model What brought us together?
Application of common principle
Firm – But Fair!
Fraud management is NOT a competitive advantage
Privacy maintained by BJ
Standard audit protocols
Licensed Investigators – Shermott Pty Ltd
AHIA Fraud Forum August 2007

5. AHIA Fraud Forum August 2007
BJ’s Believe It or Not! #1
Chiropractor introduces bonus scheme for receptionist
He allows receptionist to claim against his provider number for maximum services in the year against her own membership
Provider surprised at our belief that this money must be paid back.
Well, she won’t get a bonus!
AHIA Fraud Forum August 2007

6. Outsourced Model Central Use of Information
Information obtained at either Fund or BJ level is applied to all clients
Information can be obtained from analysis, electronic claims monitoring, industry intelligence or internal fraud awareness
For those funds where information is applicable and cost/benefit exists, joint action is taken
Only joint action funds receive report on results, thereby protecting privacy
AHIA Fraud Forum August 2007

7. AHIA Fraud Forum August 2007
BJ’s Believe It or Not! #2
Negotiations for restitution with young female Dentist stall!
‘Adult Favours’ offered in lieu of $45,000
Investigator responds with preference for a glass of red!
Expensive......!
AHIA Fraud Forum August 2007

8. Outsourced Model Joint Action
Electronic claims audits with full validation of data:
Patient Record Cards
X-rays
Study Models
Prescriptions
ETC
Compliance reviews of electronic claims process, not data specific
Fraud Investigations
AHIA Fraud Forum August 2007

9. AHIA Fraud Forum August 2007
BJ’s Believe It or Not #3
Staff member’s defence of $150,000 fraud based upon gambling problem!
Court rejects based upon $80,000 recovered in police raid
Court accepts defence of childhood hardship
Community order of 200 hours applied
Health Fund still $70,000 in arrears
Hourly rate of $350 – go figure!
AHIA Fraud Forum August 2007

10. Methods, Techniques and Tools
Have a standard claims audit model:
Based upon individual transactions and profiling
With ‘acceptable’ protocols for both provider and fund
With ‘acceptable’ standards for both provider and fund
With fully supported sanctions, and
Be ready to apply these sanctions
AHIA Fraud Forum August 2007

11. Methods, Techniques and Tools
Analyse your data:
it is rich, but it will not be perfect
Don’t assume, life is far more unusual than you will ever think
Can be simple or complicated, but based upon your action and resolve
You have every right to question, so question
AHIA Fraud Forum August 2007

12. Methods, Techniques and Tools
Understand the imperfections of your products
Often encourage manipulation, e.g % based benefits
Poor item selection
Incorrect mapping of electronic claims systems
You set annual limits!
AHIA Fraud Forum August 2007

13. Methods, Techniques and Tools
Use your right of audit, electronic and manual:
Both HICAPS & IBA provide this right
Fund rules and claim forms should protect manual rights
THELMA hospital claims provides rights
Auditing is standard business practice, and PHI is a business
AHIA Fraud Forum August 2007

14. Methods, Techniques and Tools
Do not be intimidated:
Internally by Legal
Privacy Act cover
Provider Associations
Threats of external legal action
BE FIRM, but fair!!!!!!!!!!!!!!!!!
AHIA Fraud Forum August 2007

15. AHIA Fraud Forum August 2007
Last Laughs!
Dental practice destroyed by fire one day before audit – bloody candles!
X-rays stolen in burglary – twice from same practice!
HICAPS transactions slips stolen in burglary – must be hot on Ebay!
Chiropractor performs manipulation on 3 hour old baby
AHIA Fraud Forum August 2007

16. AHIA Fraud Forum August 2007
Continued…..
16 restorations performed on truckie with full dentures
Optical provider maintains no records, didn’t know he had to!
Podiatrist sells $50 Scholl inserts as $400 orthotics, health fund pays
My Favourite
Dentist reads 8th Edition!!!!!!!
AHIA Fraud Forum August 2007

17. AHIA Fraud Forum August 2007
Questions?
AHIA Fraud Forum August 2007