To deliver affordability and sustainability for our members, we address fraud, abuse, waste and error in claiming and conduct.
If you are concerned about potentially suspicious health insurance claiming, you can get in touch with us by:
Below are some examples of suspicious claiming we would investigate:
- Intentionally fabricating or altering invoices and receipts
- Submitting claims for treatment that differs from what was provided
- Billing for treatment that was not provided to obtain reimbursement
- Unexpected claims activities on your policy
We will use the information you provide to look into your concerns carefully and sensitively, and will take all practicable steps to maintain strict confidentiality.
If you wish to access or correct any personal information you provide us, then please let us know.
You do not need to fill in all sections of this form and if confidentiality is a concern, you can choose to remain anonymous, however the more information you can give us, the more likely we’ll be able to do something to investigate the matter further.
How can members help?
- Never sign a blank form and leave it with anyone – even a healthcare provider.
- Carefully check the details on invoices and your Claim Update to ensure they match the treatment received and costs paid.
- Don't be afraid to ask questions, report issues and query invoices if you see anything suspicious in your claims history.
How can providers help?
- Ensure staff are properly trained to submit prior approval and claims on behalf of our members via our Affiliated Provider or Easy Claim portals
- Ensure Eligibility Criteria has been met prior to submitting an application or claim
- Ensure any ACC claims are submitted to ACC in the first instance
- Tell us about any refund or discounts that have happened from the original claim
- Ensuring you are using the correct date and items/codes/procedure codes on every claim
- Do not share your password and remember you are responsible for claims using your provider login
- Let us know if you are feeling pressured to make a claim
- Use our reporting form and tell us about suspicious behaviour
If suspicious claiming practices are suspected, the Society investigates and where appropriate takes steps to recover funds. The Society has a range of actions that it is able to take against members and providers. In extreme cases, where fraud or ethical issues are suspected, matters may also be referred to the police or an appropriate medical body.