1. Fraud & the e-claims channel... a HICAPS perspective
How long have we got – 30 mins ?
Leaving 10 mins for Q&A at the end, that gives us 20 mins – there is no way that I can do justice to such a broad topic in 20 mins so, I’m just going to try and make a few points regarding e-claiming as a channel & HICAPS in particular
B 4 I forget, I’d like to say thank you for the opportunity to be here for the AHIA conference and more particularly to acknowledge & thank you for entrusting us with your ancillary e-claims business which we have been ‘at’ now for eight yrs
AHIA Private Health Insurance
Claims leakage and Fraud Forum August, 2007
Greg Millane

2. Contractual – clause 4.2 (h) of the Provider Agreement
Define the topic ..….
Discussion around fraud management in the e-claim channel seems to me to fall under three categories or sub headings;
Integrity/security – of the hardware, & software e.g. data encryption, etc
Contractual – clause 4.2 (h) of the Provider Agreement
The reports & analytical tools we’ve developed to help funds successfully manage their risk exposure
just read the slide

3. 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 de identified data between the provider & the health fund
We do have an obligation to work closely with our customer funds to assist them in the management of their ancillary claims fraud risk
I think that you will all agree with me that its not hicaps role or function to investigate claiming patterns and what may/may not constitute fraud
With lots of different item schedules across the industry even if you wanted us to, I doubt that we could
We do however take the responsibility of working with our customer funds to define and deliver the appropriate tools very seriously – just offering a e-claims channel without the tools to successfully manage the risk doesn’t cut it - in our opinion….

4. HICAPS Provider Entries Coverage
171
Nationally
32,624
6,986
Just for context, with 33k provider DB entries we have a lot of Providers putting through lots of transactions
16/17 million transactions this year = more than 30 mill claims lines
2,772
9,473
3,948
ACT 443
7,959
872
Provider Entries (where a provider practices in multiple locations, each is counted)

5. #1 Integrity/security…
Terminal hardware – the same ‘spec’ as the banks
Encrypted data*
Moving 2008/09 from 1xDES to 3xDES
Software - finance industry txn standard;
$250 bill p.a. through eftpos & credit
So, step one, perhaps pointing out the bleeding obvious, safe & secure claims system ………….
The architecture, both hardware for the terminals & software for the comms & the messaging leaverages off what the banks have used for decades in the eftpos mkt.
2005 RBA data more than 20 bill txns to the value of more than $250 mill
(Inc atms)

6. the ‘quid pro quo’ of Funds accepting claims electronically …
#2 Contractual….
Clause 4.2(h) of the Provider Agreement provides Funds with the right to ask to see evidence/supporting documentation
the ‘quid pro quo’ of Funds accepting claims electronically …
It works ……….
Deeply unpopular with some Provider Associations
There is not much more that I can say here…. 4.2 (h) is infamous, and we’ve copped, and continue to cop, lots of flak over it but its not going away
not trying to impress with my latin – just means, very literally “something for something” – if we/you don’t have the right to see supporting documentation for claims you rec’d electronically then we don’t or won’t have e-claiming

7. this slide as you can probably deduce, has nothing whatsoever to do with the topic at all … just designed to get your attention back

8. #3 Reporting ….. providing the tools
The hicaps switch data is incredibly powerful….!
Two ways to analyse the claims data;
Batch reports (delivered via National On Line)
CSS - Accounts On Line (dynamic, criteria based searches)
Just read the slide

9. #3 Reporting ….. providing the tools
current HICAPS batch reports
J – MultiSwipes
K – Management Overview
L – CSS Audit Log
M – Quote Anomalies Report
N – Average Item Charge Discrepancy
O – Invalid Item Number Listing
New (via )
Automatic Rejected Providers report
Just read the slide – Brett here as well we can discuss specific reports outside of this session

10. #3 Reporting - streamlining processes
If you are not getting any of these and would use them, please let us know !
If you are getting them and don’t want them, please let us know !
If you have any suggestions about other reports, or changes to these, please let us know !

11. #3 Reporting ….. providing the tools
H.A.O- Dynamic Search Engine - was developed to allow Funds to conduct criteria based searches across a wide range of switch data.
Actively used by a number of funds
Both the search criteria and display results are fully configurable in order to deliver as much or as little information as required.
Once the result has been received you can “drill down” to the item level on any transaction.
Display results can be exported into a spreadsheet application e.g. excel.
The dynamic search capability covers data going back to May 2003
Appx 132 mill claim lines

12. The e-claim system architecture is secure
Summary
There is fraud in the e-channel just as there is in the physical or paper channel
The real question is what are you doing to detect it and manage your risk exposure
The e-claim system architecture is secure
The contractual right to ask for substantiation is of fundamental importance
We believe strongly that we have an obligation to provide you with more than just a ‘switch’ – the data & the analytical tools to manage the risk exposure
Just read the slide

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

14. Providers need to be told to keep slips
Other issues….
One item schedule
Providers need to be told to keep slips
Benefit paid on an invalid item number
Patient name
Terminal receipt