NCJ Number
180148
Date Published
1999
Length
6 pages
Annotation
Medicare, Australia's universal health insurance scheme, has been in operation for almost 25 years, and this paper examines the nature and extent of current forms of fraud and inappropriate practices in relation to Medicare and whether future technology developments will make matters better or worse.
Abstract
Australia's Health Insurance Commission (HIC) makes extensive use of information technology in processing and paying Medicare claims and benefits and in recording data on transactions carried out with health care providers and patients. The largest volume of claims comes from providers who direct-bill the HIC. In 1997-1998, about 72 percent of services were direct-billed, either through the submission of paper claim forms or electronically using the HIC's Medclaims system. The HIC also enables patient claims for refunds to be made electronically in certain circumstances. Between July 1997 and June 1998, 128,023 Medicare services valued at $7.5 million were processed by electronic funds transfer, a relatively small proportion of the 202 million Medicare services billed valued at $6,334 million. Funds may be illegally obtained from the HIC by providers. The most common offenses investigated by the HIC involve claims for Medicare or pharmaceutical benefits made by means of false or misleading statements. Other offenses include forging a patient's name on a Medicare assignment of benefit form and aiding or abetting or conspiring with another person to commit a crime. Fraud may also be perpetrated by patients who make false or misleading statements when seeking to obtain benefits and by employees of providers, such as medical receptionists and practice managers, who make false claims on behalf of their employers. In 1997-1998, the HIC indicates 2,812 complaints of alleged fraud and inappropriate practice were recorded. About $7.6 million in benefits paid incorrectly, however, were recovered or were in the process of being recovered. Because the vast bulk of benefit claims will be made electronically in the future, systems need to be developed to be sure of three essential elements: (1) the communication is from an identifiable individual; (2) the communication has not been read by a third party; and (3) the contents of the communication has not been tampered with after sending. The most secure systems that have been designed for electronic communications in recent times involve the use of public key cryptography and digital signatures. Possible future developments in Medicare fraud and inappropriate practice are examined, such as inappropriate claims, false identities, security risks associated with the introduction of a public key authentication framework, sender authentication, data transmission, and content authentication. 11 references