1. Medical Insurance Fraud
Opening slide
This is how an AXA PPP healthcare PowerPoint presentation should be introduced. All that is needed on this slide is: the presentation title and the AXA PPP healthcare logo with the ‘Be Life Confident’ strapline.
When set the logo should be 2” wide with the strapline 4” wide. The red lines should be extended 0.5” from the left and right-hand edges of the slide.
The title should be set in Eras Demi 28pt.

2. Background AXA PPP healthcare
UK second largest PMI insurer.
1.7M lives covered.
24% of insurance market.
All UK residents can have private treatment on the NHS.
Little government support for private healthcare.
Simon Peck - September 2006

3. Prosecution of fraud Not a home office priority
Until recently Theft Act
Fraud Act 2006 created new offences of fraud by:
False representation
Omission
Abuse of position of trust
This Act which was part of Fraud Review was intended to make prosecution easier.
Simon Peck - September 2006

4. Before 2000……..
Simon Peck - September 2006

5. 2008 Total A$ 3.8M savings in last 12 months ¾ doctors ¼ customers
6 cases pending against GPs - first settled for A$ 37,000
4 good cases with medical regulator (GMC) first struck off.
Simon Peck - September 2006

6. Press coverage
Simon Peck - September 2006

7. Press Coverage 2
Simon Peck - September 2006

8. Press Coverage 3
Simon Peck - September 2006

9. Herald Sun 23/6/2008
Simon Peck - September 2006

10. History 1 1990s “there is no fraud in healthcare” NHS CFSMS
FSA regulation
Increasing awareness of fraud
Contents slide
A contents slide should be used to list the sections contained within a presentation. The list is ranged left, 1” from the left-hand edge, and should be no more than 8” wide. ‘Graphic’ bullet points should be used for each section title which should be set in Helvetica Bold 24pt.
Simon Peck - September 2006

11. History 2 In 2003 AXA PPP healthcare performed audit 650 claims
Hospitals across UK
Result:
Material fraud and misrepresentation
Only one hospital where no misrepresentation discovered
Simon Peck - September 2006

12. Type of fraud/misrepresentation
Supplier:
Upcoding
Unbundling
Misrepresentation
Customer:
Non-declaration
Contents slide
A contents slide should be used to list the sections contained within a presentation. The list is ranged left, 1” from the left-hand edge, and should be no more than 8” wide. ‘Graphic’ bullet points should be used for each section title which should be set in Helvetica Bold 24pt.
Simon Peck - September 2006

13. Upcoding Procedure performed Procedure invoiced
Diagnostic laparoscopy (intermediate)
Therapeutic laparoscopy (major)
Spinal decompression/ fusion V2500
Scoliosis surgery V4100
Hysterectomy (major)
Hysterectomy for ovarian malignancy ( x Major)
Simon Peck - September 2006

14. Unbundling Procedure performed Add ons
Endoscopic resection of the prostate
Cystoscopy
Urethrotomy
Preoperative assessment
Inpatient care
Pain relief
Simon Peck - September 2006

15. Misrepresentation By false statement
By omission of material information
By use of jargon
Simon Peck - September 2006

16. AXA PPP healthcare approach
Creation of anti-fraud culture
Customer fraud team
Provider fraud team
HICFG
Memorandum of Understanding with NHS
Simon Peck - September 2006

17. Investigation methodology
Based on sanctions:
Recovery of monies (civil action)
Criminal
Disciplinary
Other - removal of recognition
Simon Peck - September 2006

18. Medical Confidentiality – a huge hurdle
Legal background:
Data Protection Act (S29, S31(2))
Common Law
(Human Rights Act)
Solutions:
Consent form
Customer Contract
Simon Peck - September 2006

19. Use of technology SAS system Ratios/patterns/unusual transactions
Look for patterns matching known frauds
The next stage is to do real data mining
Simon Peck - September 2006

20. Use of technology
Models on SAS which look for the characteristics of known frauds
Unbundling – single:multiple intervetion
Upcoding complexity profiles/incidence of unusual procedures
Cost index against peers
Real data mining
Simon Peck - September 2006

21. Example of reports run
Simon Peck - September 2006

22. Process on discovery of suspicious transaction
Source of referrals
Red flag claims
Proactive monitoring
Reports generated
Referral of suspicious transactions
Simon Peck - September 2006

23. Procedure followed on discovery of suspicious transactions
Profile of provider
Extraction of claims
Request medical records from all sources
GP notes
Correspondence
Tests and pathology results
Office review/on site review
Investigation then depends on findings.
Simon Peck - September 2006

24. Sanctions applied Recovery of monies
Disciplinary – report to regulator
Derecognition
Proven fraud
High risk providers
commerical
Criminal (rarely)
Disclosure to other companies
Simon Peck - September 2006

25. Information sharing July 2008 website www.hicfg.co.uk launched 3 areas
Public (includes whistleblowing number)
Members area (tradecraft documentation etc)
Secure area – database of suspicions
This is expected to fundamentally change the way we work and will end for ever the problem of one insurer dealing with a problem only for it to recur in another company.
Simon Peck - September 2006

26. System controls Commercially sensitive but think of: Validation
Blocked procedure combinations
Individual transaction limits
Risk based assessment – red flags
The risk of a transaction is multifactorial and you need to consider patient characteristics, the underlying condition, the underlying treatment and the service provider.
Simon Peck - September 2006

27. Publicity Numerous conference presentations Press reports
Reactions from the medical profession
Simon Peck - September 2006

28. Advice for providers of healthcare services
Communicate fees to patients clearly
Always ensure information to insurers is accurate and complete
Use codes for the intended purpose only
  Never
Give in to pressure to alter facts
Omit material information
Try to make up the difference between the charges proposed and insurance entitlement with creative billing
Simon Peck - September 2006

29. The future Increasing cooperation Fraud intelligence database
More prosecutions
Simon Peck - September 2006

30. Billing fraud - lessons we have learned
Define and quantify your problem
Design fraud out of your business
Good controls
Analysis led investigation.
Audit notes use expert assessors with clinical coding and insurance expertise.
Multi-disciplinary approach (doctor/nurse/investigator /lawyer/ analyst/accountant.
Simon Peck - September 2006

31. End slide
This is how an AXA PPP healthcare PowerPoint presentation should be brought to an end. By simply using the AXA PPP healthcare logo with the ‘Be Life Confident’ strapline, a strong, assured closing statement can be created.