1. Ancillary Benefits Leakage – What to Look For

2. Wine Appreciation 101

3. This goes with that, goes with this, goes with that…

4. Week 1
Main Courses:
Oven roasted Snapper fillet with Tuscan bread salad and
Yarra Valley salmon pearl aioli
Accompanied by ‘05’ Roche Premium Sauvignon Blanc
Beef tenderloin and pancetta with velvet potato puree and
sautéed forest mushroom
Accompanied by ‘03’ Roche Premium IJR Shiraz
Slow roasted pork with chat potatoes, rosemary & garlic
Accompanied by ‘04’ Roche Premium WR Merlot

5. Ancillary Benefits Leakage – Issues Commonly Identified

6. Issues Commonly Identified
Upcoding
Bill padding
Claiming across multiple people on a membership
Claiming across benefit years
Splitting cost across multiple dates of service
Using another provider’s number
Altering receipts .

7. Upcoding Common in dental claims
Easy to get away with as members don’t understand dental item codes or what services they have received
Used often in restorations such as
Billing for 3, 4 or 5 surface filling items ( , , , , ) instead of 1 or 2 surface ( , , , , )
Billing for indirect restorations ( ) instead of direct restorations ( )

8. Bill Padding Common in dental but also in optical Dental –
Xrays on every consultation (022)
Fluoride on every consultation (121)
Oral hygiene instruction for every patient (141)
Fissure sealing for every child patient and even some adults against clinical indications (161)
Cusp capping (577) on majority of front teeth restorations and Incisal corners on back teeth restorations (578)

9. Bill Padding continued…
Optical –
Additional charges added to bill for lens coatings including:
Hard coatings
UV coatings
Scratch resistant coatings
When most of these add ons are now intrinsic in lens design and manufacture

10. Claiming across multiple family members
When the limit for one person is reached they claim against another family member or person on same membership; or
Splitting cost across two members to get maximum claim rebate eg. glasses costing $300 split across husband and $150 each to get full rebate.

11. Claiming across benefit years
Very common across December/January and June/July when funds benefit years roll over.
Cost is often split to claim part in one benefit year and the remainder in the adjoining benefit year.
Example: member having a number of veneer services (582) and reached limit so remaining services actually performed on 29 June claimed on 2 July in new benefit year.

12. Splitting cost across multiple DOS
To increase the benefit amount rebated to a member and eliminate out of pockets the service cost is split across multiple dates of service
Example: remedial massage service with a cost of $45 performed on 3 June split into 3 services across 1, 2 and 3 June at $15 per service.

13. Using another provider’s number
Often used in multi provider practices when some of the providers do not have appropriate qualifications.
Use the provider number and name of a provider who is recognised by funds.
Have one receipt with only the one provider name and details.
Example: a massage outlet with several massage providers using the provider number of a recognised acupuncturist and charging all services as acupuncture performed by the recognised acupuncture provider

14. Altering Receipts
This if more often done by a member than provider in order to obtain a benefit when limit reached, to increase rebate, claim from an unrecognised provider or claim for a service not even provided.
Examples:
Changing date of service
Changing name of patient
Changing amount charged
Changing name of provider
Duplicating another receipt