1. Australian Health Insurance Association 2007
Private Health Insurance Claims Leakage and Fraud Forum Hon Dr Michael Armitage 23 July 2008
Australian Health Insurance Association 2007

2. AUSTRALIA 21.18 million population 10.87 million with PHI
38 health funds
758 public hospitals
278 private hospitals
265 day hospitals
2.94 million private admissions .
Overview Australian health system 2

3. Private Sector Contribution
Selected Episodes: Proportion Performed in Private Hospitals Data Source: AIHW 2008
Major procedures for malignant breast conditions
55%
Cancer Therapy (Chemotherapy)
55%
Hip Replacements
55%
Other major joint replacement & limb reattachment
63%
Mental health treatment, sameday
70%
Lens procedures
73%
Complex Middle Ear Infection
70%
Other Knee Procedures
77% 3

4. Benefits Paid for Individual Procedures for Members of PHI
12 months to 1 January 2007
Selected claims over $100,000
Source: AHIA Annual High Claims Survey 4

5. Benefits Paid for Individual Procedures for Members of PHI
Less than 30 Years of Age
12 months to 1 January 2007
Selected Top 30 High Claims, less than 30 Years of Age (excluding Premature Births)
Source: AHIA Annual High Claims Survey 5

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10. Private Health Insurance Ombudsman: Complaints 2006/07 Data Source: PHIO Annual Reports
Complaints about registered health funds
2,209
PHI Cover       
10,282,379
Transactions (Hospital, Medical and General Treatment)
78,870,668
Complaints per PHI transaction
0.0028%
PHI Complaints as a % Phi Cover
0.022% 10

11. Private Healthcare Fraud
Changes post 2007 Fraud Forum
- New Federal Government
- Premium Adjustment 4.99%
- Budget (MLS Threshold)
- Govt financial dividends from BHC and preventative healthcare
- No short term fix!

12. Private Healthcare Fraud
Health Minister – won’t approve premium adjustments based on membership decline!
Need to target every arrow in our quiver
Fraud an important arrow!
Estimate 1 - 2% claims inappropriate

13. Private Healthcare Fraud
Difficult to quantify excellent impact of Fraud Committee’s work
No question it contributes to lower premiums
Integrity of the PHI Industry
Reduces waste
Protects Govt investment (30% rebate etc)
Sends a positive message to providers, consumers and industry opponents of PHI

14. Fraud & Security Committee
Code of Conduct for the Sharing of Information.
Last year I reported that the Code had received the ACCC tick
“While making the usual caveat about not being able to give legal advice we do not see any Trade Practices issues with the Information sharing Code as it stands”
ACCC Commissioner John Martin on the 5th of March 2007.

15. CODE OF CONDUCT
AHIA legal advice: Health funds could share information only after a provider was aware that their information may be shared.
40,000 providers!
Seeking further legal advice re:
Can the AHIA notify providers on behalf of all funds without any Trade Practices Act or Privacy Act issues?

16. What is FRAUD? Suspected unlawful activity by health care
providers could include:
billing for services not provided; up-coding
duplicate billing for the same service
inappropriate service delivery that may put the privately insured consumer at risk financially
AND MORE….

17. Health Advertising 1930s

18. Beating Obesity!!

19. PRIVACY & FRAUD Health Care has come a long way!
Still a long way to go
“Rogue” providers can hide behind privacy:
Knowingly using an inappropriate prostheses
Knowingly perform unnecessary procedures
= FRAUD

20. Private Healthcare Fraud
“Healthcare fraud is a problem that’s growing and making healthcare more expensive for everyone. But working together, we can stop it.”
(Blue Cross Blue Shield Assoc)

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23. Private Healthcare Fraud
Fraud & Security Committee one of AHIA’s most active
At Committee’s instigation the AHIA will seek to partner with Medicare and health funds to produce an Australian version of the brochure
Benefits:
Government
Health Funds
Consumers
Health care system

24. Fraud “Break Out” session
AHIA Conference 2008
SYDNEY OCTOBER 8 AND 9
Fraud “Break Out” session
Colin Bridge – Medicare Australia
General Manager – Professional Services Division
Nicholas Adamo – Founder & CEO of Forensic Data Services
Specialising in Data Recovery, Data Conversion, Electronic Discovery and Computer Forensics.
Jim Gee – UK counter fraud specialist
Former NHS – 2007 joined KPMG Forensic as Director of Fraud Services.

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