1. 11/11/2018

2. Investigations Unit
Fraud Awareness
11/11/2018

3. Session Outline About Fraud Types of Fraud Motives Compensation Claims
Risk Indicators
Community Sourced information
Code of Conduct
Confidentiality
Response to members
Emerging areas of risk
11/11/2018

4. Make false statement with intent to obtain financial advantage
What is Fraud?
“Telling lies or being dishonest with the intent to obtain a benefit that you are not entitled to.”
Make false statement with intent to obtain financial advantage
178BB Crimes Act 40/1900 – NSW
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5. What’s wrong????
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6. What’s Wrong????
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7. Why should you be aware of Fraud?
Fraud accounts for nearly 20% of all reported crime in this country; OR
5.8 Billion Dollars
Around 10% of all general insurance claims are estimated to be fraudulent (ICA) - Insurance Council of Australia -
Industry estimates of PHI fraud are believed to be between 1-3% but there are no accurate figures
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8. Why commit Fraud?
Fraud is seen as an attractive alternative to other types of crimes.
The reasons include:
Socially Acceptable
Perceived Entitlement
Cheap
Little Risk of Detection
Non-Violent
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9. Health Insurance Fraud
Different types of fraud within the Health Insurance industry:
Hospital, Ancillary, Medical benefits
Contribution
Staff
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10. Hospital Hospital Fraud Upcoding Extra nights of stay claimed
Overcharging for prostheses (not implanted)
Claiming for services for which they are not entitled
Outreach services not performed, (no physical attendance)
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11. Ancillary Ancillary Fraud Limit surfing Falsifying treatment documents
Falsifying account documents
Over servicing
Padding
Collusion between Provider and Member
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12. Medical Medical Fraud Incorrect use of item numbers
Collusion with provider
Incorrect Invoicing
Treatment outside period of cover
False claims
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13. Contribution
Making claims knowing that contribution payments will be dishonored (direct debit, cheque, credit card)
Receiving 30% rebate knowing contribution payments will be dishonored.
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14. Compensation Claims
Should any information be obtained from members or other sources in relation to compensation matters being pursued by a member, this information should be relayed to the Investigations Department for follow up by our contractors.
Our contractors are:
National Health Recovery Agents - Mark Hall
For Debt recovery:
Newcomen Commercial Services - Ron Stephenson
11/11/2018

15. Staff
Making claims on receipts that are not official (made by the staff member).
Collusion with friends/family members/providers.
Changing bank account details on memberships so direct credit claims benefits will be deposited into their own account.
Knowing a staff member is committing fraud and not doing anything about it.
11/11/2018

16. Risk Indicators
Indicators for suspicious claims, sometimes known as “fraud indicators” include:
Photocopied receipts
Members statements
Phone calls where member is being prompted by another person during the claims process
Members acting suspiciously during claiming
Member not willing to sign documents
Never bringing a card with them
Always reaching $300 cash limit when claiming
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17. Risk Indicators – Ancillary
Multiple people having same service / same day
Amount Charged the same as Benefit Paid
Limit surfing ie., using the limits of all dependants on membership
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18. Risk Indicators – Hospital
Item numbers different to service provided
Item numbers not matched between hospital and specialist
Patients records don’t match care claimed (ICU)
Neonatal care claimed for well baby
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19. Risk Indicators – Medical
Overcharging
Service not carried out
Double charging – submitting the same account more than once
Changing item numbers so members can claim (level of cover)
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20. Community Sourced Information
What is Community Sourced Information?
This is information which has been provided by persons alleging a suspicious event that has, may, or will occur
People provide us with information freely and we use it to assist us for investigation purposes.
Sarbanes-Oxley Act 2002 requires effective complaint management
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21. Community Sourced Information
Why we receive Community Sourced Information
Their conscience compels them
Concern regarding the cost to the community and rising insurance premiums
Annoyed with a person/s boasting
Seeking revenge towards another person, vexatious complaint i.e. competitors
Giving the information as general interest without knowing it’s usefulness and/or relevance
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22. Community Sourced Information
A Fraud Hotline has been established to take community sourced information nationally for NIB.
9am – 5pm (EST)
Monday – Friday
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23. Community Sourced Information
The address for information is
Any documents or hand-written notes should be forwarded or faxed to:
NIB Investigations Unit
Level 2
384 Hunter Street
Newcastle 2300
Fax No
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24. Code of Conduct The NIB Code of Conduct states in part that
“...employees must report any unsafe practices or suspected corrupt behavior to their manager / supervisor who will forward the report to the Investigations Department.”
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25. Confidentiality
All information supplied either by NIB staff or community sources is confidential.
For further information please read the NIB Confidentiality Agreement published on Insite.
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26. Standard Response
“Your claim has been selected for random review and will be forwarded to head office for processing. This is not meant to cause you any inconvenience and your claim will be processed as quickly as possible.”
Should the member or provider have any concerns, they should be referred to the NIB Investigations Unit
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27. Emerging Areas of Risk Ecommerce Fraud (online claims lodgments)
Identity Fraud
Expansion of electronic claiming networks
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28. In Conclusion
Should you identify any areas of risk to the business, please report to your manager or the NIB Investigations Unit to discuss the matter.
Our commitment to you is to respond within 48 hours of your notification of any concerns. We will also keep you updated on the progress and the final result of the information supplied to the Investigations Unit.
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29. Case Examples Case Example 1. Case Example 2.
Chiropractor claiming benefits for services not rendered using the HICAPS facility. Provider profiling and investigation revealed in excess of $28000 in overcharging which was refunded to NIB.
Case Example 2.
A part time dental receptionist who was also a member of NIB was fabricating false invoices for dental treatment for both her and her husband which were not performed. Police have charged the member with numerous counts of fraud relating to the deception of NIB and other financial establishments. Over $8000 was refunded to NIB by the member.
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30. Question Time??
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