Building Relationships with Ancillary Providers: Clarity, Fairness, Procedure, Compliance

1. Building Relationships with Ancillary Providers:Clarity, Fairness, Procedure, Compliance AHIA Claims Leakage Forum Jim Durkin BUPA Australia Health

2. PHI & Ancillary Providers • The Provider Recognition Journey - The Elements • Strong desire as a health fund to enhance the compliance culture • ‘What is in the best interests of our customers?’ - Quality, affordable services • What expectations do we have regarding provider behaviour? • What can and should they expect of and from us? • What can we do if we want to end our relationship with a provider?

3. PHI & Ancillary Providers • The Provider Recognition Journey - The Elements (cont.) • We introduced a regime of recognising, counselling and de-recognising providers • But, terms and procedures in need of review • Involvement from Provider & Legal • Re-write of ‘Our Ancillary Provider Terms’ • Also, ‘What happens if You Breach Our Ancillary Provider Terms’ • Accompanying De-recognition and Re-recognition (Yes, re- recognition!) Procedures

4. PHI & Ancillary Providers • Registration and Accreditation of Ancillary Providers • Three categories of Ancillary Provider Recognition: • - Medicare Australia registered • - Providers via Medibank Private • - Alternative Therapies • Reasonable assumptions re MA & MBP • Need to be more explicit regarding our expectations for alternative therapies - insurance, 1st Aid, qualifications • Providers mostly referred by Professional Associations • Some alternative therapists required specific checks

5. PHI & Ancillary Providers • Registration and Accreditation of Ancillary Providers (cont.) • Medicare Australia recognised - Dentists, physiotherapists etc OK re: criteria, but still require our Terms • Medibank Private recognised - the same • Alternative Therapists assumed OK if referred by an Association • The ‘$150 check’ • Could we be certain about the Association members • Formulated Association Accreditation Criteria

6. PHI & Ancillary Providers • Registration and Accreditation of Ancillary Providers (cont.) • Association Accreditation Questionnaire • Documentation - education/quals, Constitution/Charter, Code of Ethics, CPE program etc • ‘Undertaking to Comply’ signed by Association rep. • Audits conducted by BUPA Australia • $150 for non-association members - uncompetitive? • Received ‘Immunity from breach’ from the ACCC re: third line forcing • All information on the ACCC website, including all Terms etc.

7. PHI & Ancillary Providers • Communication & Education Campaign - The Terms • All relevant associations advised of our intention to re-write and distribute these Terms • Meetings, discussion, input, advice • Markedly different responses depending on the association • Established Alternative Therapy Assoc’s eg AACMA, ANTA etc welcomed with open arms • ADA - Confused ‘recognition’ with ‘registration’ • APA - reasonably supportive and provided input

8. PHI & Ancillary Providers • Some Subjects covered in the Terms • How do you agree? • What must You do? • What must We do? • How do we confirm claims are correct? • Privacy & Confidentiality • When can We end Our relationship with you? • How will this happen? • What happens if You have committed a breach of the Terms that can be fixed? • What happens if you commit a serious breach of these Terms? EG criminal, dangerous

9. PHI & Ancillary Providers • What happens if You Breach Our Ancillary Provider Terms? • Specific document with in-built procedure • When will we conduct an investigation? • What happens if we believe you have breached the Terms? • What if you disagree? • What if we need more information? • How do we ensure that We make an objective decision? • What happens after we have considered your submission? • What types of decision can We make? • What happens if we commence steps to end Our Relationship?

10. PHI & Ancillary Providers • Where does Counselling fit in the Recognition Process • Dental issues are complex • Issues of concern raised with providers • SPP/BPP often point to other issues • Specific provider data to Dental Adviser • Victoria - Dr Gerry Clausen; South Australia - Dr Peter Clarke

11. PHI & Ancillary Providers • Where does Counselling fit in the Recognition Process (cont.) • Interim reports and counselling recommended (or not) • Provider asked to attend counselling and bring records • Counselling usually resolves issues (Rules? Glossary? Crowns!) • Occasionally behaviour is clearly intentional, therefore de-recognition proceeds • Practices and stats improve post-counselling

12. PHI & Ancillary Providers • So, why is everything not entirely perfect? • We now state that we ‘de-recognise You in accordance with Our Terms’ • To be of any use, the Terms have to be in the provider’s possession • We have continued to de-recognise providers where a breach is clear and intentional • Guild Legal have politely pointed out where Terms not provided • We can still seek restitution, remove CPOS etc but…. • Forward Terms and start again • Currently de-recognised - 5 Optical; 2 Physios; 15 dentists; 7 Alternative Therapists

13. PHI & Ancillary Providers • What are we doing to resolve this? • Spending the money to distribute to approx. 30,000 providers • They will all have the Terms so no excuse • We are scouring the Terms to identify and anticipate any changes • Already earmarked a clause for ‘sharing information’ • Seeking external legal advice on procedures re: other parties and undertakings • Eventually e-mail and our Website will take over

14. PHI & Ancillary Providers • Some advantages in Providers having the Terms • Keeps them honest in their behaviours • Keeps us honest in our dealings and treatment • If ACCC, PHIO or the media pay us a visit we’re compliant and protect our reputation • Provides consistency, clarity, fairness and procedure • Once they have them, no excuses • Allows us to share information • Allows us to confidently de-recognise • Formalises the re-recognition process

15. PHI & Ancillary Providers • DISCUSSION/QUESTIONS?