Fraud crackdown spreads through insurance sector

Fraud crackdown spreads through insurance sector | Insurance Business

Fraud crackdown spreads through insurance sector
Health insurance mutual Southern Cross Health Society (SCHS) is appealing to its members and healthcare providers to help in its crackdown on fraud in their midst with the launch of a new 0800 number.

The appeal comes as moves have been made across the wider industry to catch fraudsters with the relaunch this month of the Insurance Council’s Insurance Claims Register which has real time ability to red flag suspicious claiming behaviours.

SCHS has a specialist team dedicated to preventing, detecting and investigating suspicious claims, not just by members, but also poor billing practices by healthcare providers.

Head of finance, risk & compliance for SCHS, Stefan Azzopardi, said he encouraged anybody who was aware of suspicious claiming behaviours or irregularities affecting the business to confidentially call the new dedicated hotline 0800 420 055.

“The vast majority of members and healthcare providers can be relied upon to act honestly and with integrity – however, claiming irregularities for health insurance are real and the Society won’t tolerate dishonesty.”

Azzopardi estimated the savings for members made from the team’s work to date at $1 million in ongoing annual claims costs, with investigations often being sparked off by member tip-offs.

But fraudulent activity by healthcare or medical providers could be even more costly, he said.

“While the most obvious claims brought to our attention involve members who file claims for services or medications not received, or submit altered bills or receipts, billing and administration practices by a small number of medical providers have also posed challenges.

“With medical providers, given the potential patient volumes, claims we investigate can involve large sums and pose a much greater financial risk to the Society.”

Typical suspicious behaviour from medical providers could include accidentally or deliberately billing for services not provided to obtain reimbursement.

SCHS had a range of actions it could take on investigation of shoddy or suspicious practices, including banning members or referring matters to the police or appropriate medical body if criminal conduct or ethical issues were suspected.

Azzopardi said ways to avoid suspicious behaviour occurring was by taking care to never sign a blank form and leave it with anyone, even a healthcare provider and ensuring details on invoices and claims assessment advice forms matched the treatment received and costs paid.