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Your Claims Cost team is working for you

10 March, 2016
article-claims

It is estimated that millions of dollars are lost each year within the Private Health sector through fraud and inappropriate claiming. CBHS has a no-tolerance policy for inappropriate claiming. Our Claims team meticulously assesses each and every claim that comes through our door, identifying and investigating any suspicious claims, while ensuring that members who've made legitimate claims receive their benefits in a timely manner. The Health Insurance Industry as a whole takes a dim view on inappropriate claiming as it places avoidable upward pressure on member premiums.

Some examples of inappropriate claiming are as follows:

  • Misuse of a Provider number: non-registered providers claiming under another provider’s details in order to receive a benefit from your Health Fund
  • Claiming for services not provided: an example of this behaviour might be claiming for both Massage and Acupuncture when only Massage treatment was provided
  • Claiming benefits from family membership limits: claiming a benefit against family members on your Card when they did not receive any treatment
  • Multi swiping of cards without your knowledge: providers or practice staff use your CBHS Membership Card to swipe multiple times; ‘fishing’ for higher benefits or other policy members’ entitlements

How you can help:

ClaimsLeakageImage
  • Check if the Provider giving you the treatment or service is the same Provider specified on the receipt
  • Check the correct member or dependant/s name is on the receipt/s
  • Check the correct service/s is on the receipt eg Massage or Acupuncture treatment
  • Check to make sure your provider is licensed and recognised by CBHS for the treatment or service being provided: https://www.cbhs.com.au/members/claims-information/recognised-providers
  • In the case of Massage or Acupuncture, check your receipt for the therapist’s name – if you always see someone different but the same therapist’s name is on your receipt then you may have been treated by an unqualified therapist.
  • Check the therapist's office has a business licence or establishment licence. This can either be inside a private practice office or within a spa or clinic setting and is usually on a wall or desk.
  • Sign the receipt if using HICAPS/iSoft once you have checked and confirmed the information is correct.  Please see the example of a HICAPS receipt (source: www.HICAPS.com.au) explaining each area and what you are declaring to be correct.
  • If you notice any discrepancies please email the Claims Cost Team at claimscostteam@cbhs.com.au who will investigate your claim.
  • Always check your claims history – this is available via CBHS member services at www.cbhs.com.au/login. Once you’re logged in, go to Claims/Claims Status and History – complete details and tick box “include provider remittances”. This information will show the date of service, member name, type of service claimed, provider’s name, fee charged and benefit paid.

CBHS has a zero tolerance for fraud. Further information on Fraud Vigilance can be found on the CBHS website at https://www.cbhs.com.au/members/claims-information/fraud-and-vigilance

Some examples of the outcomes of our efforts over the last 12 months are:

  • Investigated and unauthorised a number of Providers for inappropriate billing practices
  • Removed certain providers from electronic claiming so that each claim is manually assessed by CBHS. This ensures each claim is accurate and legitimate
  • Cancelled members’ policies where they were found to be intentionally claiming inappropriately
  • Provided written notification, including the details of the type of fraud, to Australian Prudential Regulation Authority (APRA)
  • Reported policy holders to Police for committing fraud

Please advise CBHS of any anomalies as soon as possible and we will investigate – any anomalies may be found to be intentional / unintentional. Details can be emailed to claimscostteam@cbhs.com.au

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