It is estimated that every year, millions of dollars are lost within Private Healthcare through acts of fraud and inappropriate claiming. Every dollar fraudulently claimed ultimately impacts negatively on the premium of those that hold private health insurance.
What is Fraud?
Receiving a benefit payment where there is no legitimate entitlement, submitting deliberately misleading or false information or withholding relevant information.
How Could This Happen?
By a healthcare provider or health fund member providing misleading or false information, or withholding information to gain a financial advantage for themselves or another person.
Examples of potential fraud against Private Health Insurance:
- Charging for treatment(s) that have not been provided
- Creating false documents
- Altering accounts to increase financial benefits
- Claiming for additional services without the healthcare providers’, health fund members’ knowledge
Impact of Fraud
Australia’s health care system has finite funding; for Private Health Insurance this is the sum of premiums paid into insurers. Fraud causes resources to be diverted away from payment of necessary services to pay illegitimate claims which ultimately impacts everyone due to a need to increase premiums.
To combat those losses Health Funds around the world engage in a variety of activities designed to either prevent such losses or detect and recover them on behalf of their members. Private health members, the general public and healthcare providers are a vital part of that role and are encouraged to report concerns.
Reporting a Concern
The vast majority of people are honest and use Private Health Insurance services fairly, but if you have information about someone misusing these services, please contact the Private Health Insurer(s) involved directly.
You can remain anonymous, and the information you provide will assist in ensuring funds support those who really need them.
If your concern relates to:
- A specific fund(s), please contact the fund directly
- A general concern or you are not sure which fund to contact, please email Private Healthcare Australia
- Fraud by health providers or practice staff involving payment concerns about Medicare benefits, Pharmaceutical benefits or Child Dental Benefits Schedule payments, these concerns should be directed to the Reporting incorrect billing, claiming, or suspected fraud | Australian Government Department of Health and Aged Care
- The manner or effectiveness of your treatment, rather than charges relating from it, concerns can be raised to the Australian Health Practitioner Regulation Agency (Ahpra)
More Information
Professional Services Review (PSR)
Australian Competition and Consumer Commission