Watch out - there's fraudsters about!
- SA Updates
Health insurance fraud occurs when claims are submitted to a health fund for services which have not been provided to obtain a financial benefit.
Sometimes the fraudster is a person associated with the practice or it may be that a patient, health fund staff or private individuals have intentionally falsified documents.
How to protect yourself.
Your patient’s private health insurance membership card and/or their Medicare card should never be retained by the practice. Wherever possible, HICAPS claims should be submitted on the day/time services are rendered. Item codes should be nominated by the clinician who performed the services. Item codes entered into the HICAPS terminal should exactly match those entered by the treating clinician in the clinical record. The HICAPS agreement stipulates that the first copy of the receipt is to be signed by the health fund member (patient) and the signature checked against the signature on the card (or in the digital wallet). All transaction receipts must be retained for a minimum period of 12 months.
What to do if you receive a telephone call.
If your practice receives a telephone call from a person who says they represent a health fund or otherwise from a non-verifiable source, staff should politely decline to provide any information over the ‘phone. Instead, ask the caller to put their request in writing (via email) so that it can be actioned by practice management. If you are unsure whether the request is genuine, obtain assistance or advice prior to responding.
What to do if you receive a letter.
Private health insurers and Medicare commonly conduct compliance audits to verify the integrity of benefit payments they have issued. If you receive a letter from a health fund or Medicare requesting patient records or financial information, contact the ADA (SA Branch) or your PI Insurer to obtain advice and guidance on responding.
Suspicious activity.
Health insurance fraud can occur when:
- A genuine invoice issued by the practice is manipulated – for example, by the addition of extra item codes or submitting the same invoice under multiple provider numbers or under the names of multiple fund members
- Details of an invoice are copied and used to submit non-genuine claims – for example, a fake name or membership number is used
If you are concerned, you should seek advice before releasing confidential patient details or financial information. Your ADA branch can provide guidance and assistance upon request.
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