1. Group Loss Prevention Awareness
Wayne Stone
Manager
Group Loss Prevention Awareness
HBF Insurance

2. Case studies..
Provider Fraud
Employee Fraud
Member Fraud

3. Amidi-Mazaheri – Dentist
2004 Concern received through fraud hotline relating to:
Over servicing
Padded claims
Poor clinical treatment

4. Initial Enquiries
In practice with girlfriend & dentist Mogjan Azari and had recently opened private practice to supplement NHS work.
Was ‘flash with cash’ and had recently spent almost $200,000 on a new car.
No history of Amidi-Mazaheri could be found in Iranian dental training colleges.
Highlight deal with wrongful activity first as this is what is within the policies.

5. Review
600 patients participated in clinical reviews to determine validity of claims:-
Many of services items claimed had not been performed
Those that had been performed were of very poor standard
Tales of:
Major procedures completed without injection
Inability to stem bleeding
Dental tool being dropped down throat of patient.

6. Action Mazaheri & Azari arrested & interviewed Admissions:
Padding & falsification of claims to value of $250,000
Mazaheri not qualified to practice
Had assumed identity of dead dentist with similar name
Failed asylum seeker
Azari had allowed him to gain experience practising on her patients

7. Sanction Mazaheri – Sentenced to 2 years imprisonment
Azari – Sentenced to 12 mths imprisonment
De-registered by General Dental Council
Civil action led to recovery of in excess of $200,000

8. Things to consider? Consider the bigger picture
Don’t always assume others have done their job!
Be prepared to raise concerns with professional bodies
Review internal registration procedures

10. Employee Fraud !
March 2005 Anomaly identified with health service claim on recently cancelled policy
Initial enquiries:
Provider denied providing service
Member denied submitting claim.

11. Employee Fraud ! Video footage confirmed processing employee
Subsequent analysis of policies confirmed:
73 claims processed against cancelled policies in previous 12 months
Cash paid in excess of $30,000

12. Evidence
Member pro forma’s developed to confirm / deny legitimacy of claims
Based upon initial responses evidential fraud package relating to 18 offences passed to police

13. Action Employee arrested at home address
Interviewed and fully admitted and later charged with 61 offences – Theft servant
July 2005 received:
18 mth suspended prison sentence
12 mth supervision order
150 hours community service
Continues to repay monies

14. Things to consider Don’t always think external!
Know your systems and their weaknesses
Run analysis to target those weaknesses
Promote a zero tolerance culture
Be prepared to produce a package of evidence

15. Member Fraud
April 2006
Concern through fraud referral process following receipt of dental account where service cost was below HBF tariff.
Analysis showed further similar claims relating to same member and provider

16. Enquiries New policy PO Box address
Provider had no record of treating member
Accounts provided were not in providers format
Attempts to contact member were rebuffed
Evidential package prepared for police

17. Action Member arrested and fully admitted submission of false claims
Decision taken by police to caution due to illness…..
Decision taken to charge due to previous Medicare fraud
Fined $500
Repaid all monies
Declared unacceptable member

18. Things to consider Ease of obtaining medical insurance
Benefits far outweigh premiums
Analysis needs to consider all things out of ordinary
Adopt a zero tolerance culture

19. Themes All referred through fraud/concern processes
All had issues not readily apparent
In all cases financial restitution was sought & obtained
In all cases zero tolerance was shown