NCJ Number
86648
Date Published
1981
Length
13 pages
Annotation
This article describes the methods used by the Australian Government to contain and investigate medical benefits fraud and overservicing, with particular attention to privacy rights and patterns of servicing.
Abstract
The Australian medical benefits system has no limit on the total amount payable, and one of the methods used to counter runaway medical benefits payments is the use of procedures to combat fraud and overservicing by doctors. Fraud is statutorily defined as the submitting of a false or misleading statement for payment of an amount under the act, and overservicing is statutorily defined as the provision of medical services which 'are not reasonably necessary for the adequate medical care of the patient concerned.' While the identification of fraud is a relatively clearcut matter, the issue of whether or not services are excessive is a professional judgment. This judgment is provided by committees consisting of five medical practitioners who reflect a wide range of general and specialist practice. The Department of Health has recently introduced a computerized fraud and overservicing detection system which is capable of producing each quarter a statistical summary for each doctor who has had claims lodged that quarter for medical benefits. In any investigation, the privacy of the doctor or patient is well protected through legislation that proscribes the unauthorized divulging of information on individuals. Procedures of investigation are so designed that there is minimal disruption of a doctor's practice. Fraud prevention measures include the employing of seven doctors as medical counselors who visit doctors and advise them on acceptable billing practices. A sample computerized profile report is provided.