Southern Cross cracks down on suspicious claims

Tuesday , 24 November 2015 by Aimee Bourke

Southern Cross Health Society is cracking down on suspicious claiming and poor billing practices with the introduction and promotion of a new 0800 number – 0800 420 055.

Stefan Azzopardi, Head of Finance, Risk & Compliance for Southern Cross Health Society said, “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.

“Common sense tells us that when we’re paying 73% of the country’s health insurance claims, we need to be vigilant as any unnecessary costs are ultimately met through premiums.”

The Society has a specialist team dedicated to preventing, detecting and investigating suspicious claims, whether they involve deception, poor administrative practices or billing errors.

To date, the work from this team has saved members an estimated $1 million in on-going annual claims costs - and investigations are often due to member tip-offs.

Azzopardi says, “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.”

Suspicious claiming from medical providers could include accidentally or deliberately billing for services not provided to obtain reimbursement.

If shoddy or suspicious practices are suspected, the Society investigates and where appropriate takes steps to recover funds.

The Society can also ban members and has a range of actions that it is able to take against providers. In extreme cases, where criminal conduct or ethical issues are suspected, matters may also be referred to the police or an appropriate medical body.

Azzopardi highlighted several ways a member can help in the fight against suspicious claims:

  • never sign a blank form and leave it with anyone - even a healthcare provider
  • carefully check the details on invoices and your Claims Assessment Advice to ensure they match the treatment received and costs paid
  • don’t be afraid to ask questions and query invoices.

He encourages anybody who is aware of suspicious claiming behaviours or irregularities affecting Southern Cross to confidentially call the dedicated hotline - 0800 420 055 - or email [email protected]