Stefan Azzopardi, head of finance, risk and 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 ongoing annual claims costs - and investigations are often due to member tip-offs.
Azzopardi said advisers were not a problem for Southern Cross. “They tend not to get involved in the claiming process – a few take on that extra responsibility but is so marginal it’s not an issue.”
He said international estimates were that up to 3% of health insurance claims were fraudulent, which would equal up to $20 million in claims costs a year in New Zealand. “That’s quite a significant number.”
Tackling that would reduce the cost to other members, he said.
Fraud was most often things such as altered invoices from members, or suspicious coding from providers who might submit a claim with a code for a more expensive procedure than the one they carried out.
“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,” he said.
Azzopardi said anybody who is aware of suspicious claiming behaviours or irregularities affecting Southern Cross to confidentially call the dedicated hotline - 0800 420 055 - or mail fraud@southerncross.co.nz
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