Questions

Funds & Medicare

  1. What do you find are the most effective methodologies (hospital, medical and ancillary) for :
  2. Detecting “fraud”
  3. Preventing “fraud”
  4. Recovering funds
  1. How do you define count and measure “fraud”?
  1. Do you all have savings targets and what do they represent as a percentage of benefits paid or as Return on investment (ROI) and how are your savings split between recoveries, behaviour modification and deterrence?
  2. What type of rules do you have to limit fraud or leakage up-front and how do those rules vary between modalities and between hospital, medical and ancillary?
  3. How do you ensure effective recoveries in hospital, medical and ancillary? What percentage of recovery sort are received?
  4. How do you overcome the privacy objections raised by providers to allow you access to patient data?
  5. Are there geographic hotspots for fraud and abuse that you target?
  6. How do you limit identity fraud given that Medicare knows there are multiple Medicare cards and secondly, funds have no identity checks and people can buy multiple memberships legitimately with the intent of rorting the system?
  1. What are the views of the panel on the potential for new forms of benefits leakage under Broader Health Cover?
  1. Why have various parties chosen the different tools they use, for example, SPSS, SAS, NetMap and others?
  1. E-Transactions? Risks opportunities (online)
  1. What we do, i.e. volume of transactions (benefit outlays/contributions)?
  1. Clinical team meetings – who has them benefits?
  1. Medical Specialists; reasons for interest?

Funds

  1. Which specialties (hospital, medical and ancillary) are most susceptible to fraud and abuse in your experience? Are there areas that you target, and in what priority order?
  2. What trends in utilisation have you found in individual modalities following their going on to HICAPS?
  3. Have funds found differences in the behavior of professional associations in individual states to resisting fund activity in the leakage area and does this differ between modalities?
  4. What have individual funds experienced being with online ancillary claiming with regard to “fraud”?
  5. What up-front rules have been inserted to prevent this and how effective have they been?
  6. What percentage of claims are checked for “fraud” after processing, and what has been found?
  7. What percentage of claims are paid in real-time as opposed to being processed subsequently?
  8. How extensive is member fraud and what recoveries do you make?
  9. Do you take civil action to recover monies falsely claimed by members?
  10. How extensive is staff member fraud and what recoveries do you make?
  11. Do you take civil action to recover monies falsely claimed by staff members?
  12. To what extent do you believe that the figure of 3 to 8 % for fraud in the NHS would be the same in Australia given that the NHS is a government controlled system with extensive powers whereas we operate in a private sector environment with lesser powers and somewhat different inputs to the system?
  13. What is the panel’s view on the statement made that you can mathematically determine how long a fraud will potentially run before it is discovered?
  14. How do you enforce Informed Financial Consent (IFC) if it is not in the Health Act?
  15. Have you ever come across the situation with HICAPS where there are syndicates working on either dental or optical services?
  16. How do funds resolve the inherent tension between their marketing arms (who wants to maximize claims paid in order to attract members) and fraud staff who want to ensure claims are paid only according to fund rules (there are many anecdotal reports of fund staff encouraging claimants to “vary” aspects of their claim in order to maximize benefits)?

Medicare

  1. What is the potential for sharing information between Medicare and the funds at a “high” level to prevent fraud and over servicing in such a way as to overcome objections regarding privacy?
  2. What are the CMBS items that Medicare sees as the mostsusceptible to abuse? What are the medical specialties that are most susceptible to abuse