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Health insurance fraud under the microscope

Malcolm Hopwood

Private health insurers in New Zealand have agreed to establish an integrity register to tackle fraud and undesirable billing practices in health insurance, believed to cost $29 million in claims every year.

The insurers are members of the Health Funds Association of New Zealand (HFANZ) which is setting up the register from October 1. The HFANZ estimates up to 5 percent of health insurance claims are fraudulent which costs $22 in premiums for every private health insurance member.

An industry established Counter Fraud Group in England believes fraud in the United Kingdom amounts to between 280 and 420 million pounds per year in bogus claims to private medical insurers.

The cost to the National Health Service is a huge 3-5 billion pounds. Health insurance fraud in the United States is estimated at $125-$175 billion annually.

HFANZ Chief Executive, Roger Styles, says the integrity register, to be maintained by PriceWaterhouseCoopers, will enable members to tackle fraud on a more consistent basis and will give the industry a truer idea of its scale, ensuring a very clear zero-tolerance message is delivered to those who knowingly commit it.

"Health insurers are trying to keep a lid on rising premiums and eliminating fraudulent claims would help this," he says.

Deputy Chair of HFANZ and CEO of Accuro Health Insurance, Geoff Annals, explains that an unusual billing practice, discovered by a member, will be sent to the register which will then cross-reference it to determine a pattern or the extent of the fraud.

"If there is clear evidence of fraud the case will be referred to the Police and members themselves will take whatever sanctions are appropriate against the supplier or customer," Geoff Annals says.

"Sometimes members have been blind to practices in the past but collectively we can address it. It’s in the interests of our members that we stop this."

Fraud can take a variety of forms. For example suppliers (hospitals and doctors) might bill for services, procedures and/or supplies that were not provided, submit duplicate bills, charge for items that would normally be free or perform medically unnecessary services in obtain insurance reimbursement.

Customer fraud could take the guise of using someone else’s coverage or insurance card, filing claims for services and medications not received, double invoicing or forging or altering bills or receipts.

Roger Styles says the register will be able to flag suspicious activity such as when a patient claims for more than one heart bypass on the same day or a cardiac stent prosthesis during a hip replacement.

"We want to impress upon the vast majority of suppliers and customers that they have nothing to fear from the integrity register. However it’s about fairness, honesty and ensuring our members receive good value from their health insurance policies," Geoff Annals says.