• For full information on generic scams, please click here
  •  

    Recently listed scams are highlighted in red in the table below.
    FRAUD SCAM INFORMATION
    Discipline Fraud type Brief Description Detailed Description Risk Rating Source Category Recommended PHI Action:
    Chiro, Massage, Physio Provider (Merrylands) Provider first came to our attention after almost $32,000 of benefits were claimed through HICAPS on 31/12. Onsite audit revealed little to no treatment notes. Benefits are claimed for all modalities on the same date of service. Provider has also up to 15 refer a friend payouts. Medium- unsure if provider is targeting other funds Identified from HICAPS report HICAPS suspended, further investigations still active Look for large benefit amounts being paid to same provider towards end of year.
    Multiple Member Believed to be an international fraud ring (based in China) targeting Australian insurance companies. Up to 12 fraudulent policies were opened and claimed up to $35,000 worth of claims. A routine audit check uncovered the same IP address linked to 12 policies. May also have fraudulently claimed refer a friend payments. Medium- may be happening to other funds where online claiming is immediately accessible IP address reports Memberships closed, reported to police Undertake IP reports.
    Dental Provider Provider originally charged for crown on specific tooth and then claimed same item and tooth ID multiple times in following 12 months   Medium- other funds may restrict crown benefits on same tooth ID Identified by data analyst Treatment notes requested, where no evidence to support multiple crowns, overpayment requested Check crown rules
    Dental; Optical; Chiropractic; Member Member creating accounts and then attending several different branches in short period to claim [Regional NSW] A member of the fund had been creating a large number of invoices and then attending three different branches of the fund to make claims using the falsified accounts. The member received mainly cash with smaller amounts being credited into her bank account We are unsure if the member has concurrent memberships with any other funds. Identified by branch staff in one of the affected branches Investigation underway All funds should check for occurrences where members have claimed at three different branches in a short period and the some of money paid on each claim was >$200
    Acupuncture; pharmacy; speech therapy; chiropractic; dental; physiotherapy Member Two memberships working together to create false accounts and claim [Metro Sydney] Two different memberships have been working together to create a series of falsified accounts and then attend several different branches of the fund to make claims. We are unsure if these two members have concurrent memberships with any other funds. Identified by branch staff member due to spelling errors on the invoices Investigation underway Warn claims assessors to be extra vigilant to watch for spelling errors on accounts. For example “have a mice day”. Both members also made other spelling mistakes including the suburbs of the providers clinic, descriptions of services and street names.
    Speech pathology Member Member changed the name on accounts to another of her children after one of children reached his limit Member changed the patient details on the account when the child reach the limit of speech therapy. Only the original child has ever received treatment from this provider We are unsure if this patient has cover with other funds (highly unlikely as fraud localised to one modality) Identified through the branch who raised the question if we can accept accounts that are emailed to the member Investigation underway Warn claims assessors that if they receive accounts where the member says they received the invoice by email from the provider, to check with the provider that the patient was actually treated on the date on the invoice.
    Chiropractic Provider [Metro Sydney] Provider claiming through HICAPS for patients not present Provider has been adding extra patients to the HICAPS claims when they were not present to reduce the gaps for patients Medium- we believe this may have been happening to all health funds that had members treated by this provider Member identified when a legitimate claim was declined Matter has been referred to HCCC and is currently being investigated by them Check for patterns where all members of the family having chiropractic billed through HICAPS on the same day
    Optical Provider [Metro Sydney] Provider claiming through HICAPS for patients not present Provider has been adding extra patients to the HICAPS claims when they were not present to reduce the gaps for patients and gives the member a ‘store credit’ for any additional balance that they can then use to purchase unscripted sunglasses Medium- we believe this may have been happening to all health funds that had members treated by this provider Call centre staff member picked up the claim and spoke with member Being investigated with outlook of referring to HCCC Look at optical outlets claiming all members of the family through HICAPS on the same day
    Dental Provider [Metro Sydney] Provider processed claims through HICAPS that are highly unusual combinations and has refused to supply evidence to support the claims The provider has billed through HICAPS for services that our dental advisor believes would not be provided to a patient of that age. Also on sum days the extent of services billed appears extremely excessive High- we believe this may have been happening to all health funds that had members treated by this provider HICAPS- K Report- we had a series of VERY large claim for a membership Brief for HCCC being drafted Funds should look for sleep apnoea devices on children; removal of teeth requiring excision of bone on children as young as 6 years; filling and crowning teeth previously extracted.
    Physiotherapy Provider [Metro Sydney] Provider has processed claims for 4 different memberships within the space of 3 minutes for 12 consultations Provider appears to be keeping membership cards for a few different memberships and then processes a large number of consultations across the 4 memberships within a short space of time Medium- we believe this may have been happening to all health funds that had members treated by this provider Clustering analysis of the HICAPS claims[ since has come up in the HICAPS P Report] Outlook of referring to the HCCC Look for groups of memberships having physiotherapy claims processed within the space of a few minutes (1-on-1 consults)
    All modilities Provider Provider; Claiming Self treatments Claiming consultations for themselves against their registered provider number Medium – we believe this may happen to other funds where a provider is both a member and a registered provider with a fund Indentified from nib data reports Recoveries and education letter sent to provider All funds should review registered providers who hold policies with their fund
    Chiropractor Provider {Travelling distance between each location 100kms} Provider; claiming via HICAPS at 2 separate locations in short time period Claiming via HICAPS for consultations on the same day at different registered locations that would not be possible within travelling distance of each claim (e.g. 100 km) Medium – other funds could run reports where a provider is registered at separate locations located outside a ‘reasonable’ distance for same-day claiming Identified from HICAPS Reports Providers suspended All funds could review and compare times of claims on the same day for providers who are registered in different surburbs
    Chiropractor Provider Provider: Poor record keeping Providers claiming for an excessive number of nib customers per day, resulting in nib paying for benefits without a record of treatment in the customer records. Medium – this may happen at other funds Indentified from HICAPS reports Providers suspended All funds could review HICAPS reports and then conduct an audit of customer records
    Remedial Massage Therapists Provider Submitting receipts to nib customers where the name that appears on the receipt is not the person that received the treatment Providers; submitting receipts where the name that appears on the receipt is not the person that received the treatment, or where the name of the provider that appears on the receipt is not the provider who performed the treatment Medium – this may happen at other funds Tip off Providers suspended nib conducted an onsite audit
    Different modalities within the same location Provider {Melbourne} Provider; bundling non-reimbursable items within their consultation fee and claiming via HICAPS Non-reimbursable items such as imported medications, herbal medications, herbal tonics and similar medications have been bundled together and claimed via HICAPS as a consultation fee. This was detected via an audit of records. Medium – this may happen to other funds where multiple providers are registered in the same location Identified by rule firings Providers suspended All funds could review HICAPS claims where the consultation charge appears unusually high
    Claiming for different modalities at the same centre when service not attended Provider {Melbourne} Provider; limit surfing via HICAPS with multiple providers at the same locations that are registered under different modalities Multiple provider numbers for providers that are registered under different modalities swiped via HICAPS until a benefit is paid for the same customer Medium – where multiple providers are registered at the same location Identified by rule firings Providers suspended All funds could review HICAPS claims where multiple provider numbers have been swiped until a benefit has been paid at the same location
    All modilities Customer Customer; claiming via nib online facilities with fraudulent invoices Customer; claiming via nib online facilities with fraudulent invoices. These invoices included both ancillary and hospital documentation Medium -this may be happening to other funds where online claiming is available Identified by rule firings for exceptionally high charges Customer’s membership terminated; reported to police and PHIAC Review and audit claims submitted via online facilities
    Optical Provider Optical providers swiping via HICAPS for Orthokeratology, when a $0 benefit returns, and industry code is then changed to Contacted Lenses HICAPS reports identified where optical providers have swiped for Orthokeratlolgy which returned $0 benefits, then within 2 minutes contact lenses have been claimed. Both claims are for the same charge Medium – if fund does not pay for Orthokeratology Indentified by rule firings for exceptionally high charges Recoveries letter sent to all Optical providers identified from HICAPS reports Review HICAPS reports to identify where a claim has been swiped resulting with $0 benefits for Orthokeratology and then within a few mintues another claim is swiped with a different industry code (usually contact lenses)

     

    Back to top