ERIC PAN (#6) z 3329915 DAVID KIM (#17) z3220406

1. FRAUDINOPTOMETRY ERIC PAN (#6)z3329915 DAVID KIM (#17) z3220406

2. Definition of Fraud “Any deceitful or dishonest conduct, involving acts or omissions or the making of false statements, orally or in writing, with the object of obtaining money or other benefit from, or evading a liability.” (Medicare Australia) • Example: Recently mentioned David Ford who in 2012 billed Medicare for a comprehensive consultation when only 5 minutes of actual eye-related activities had occurred and instead engaged in sexual intercourse!(AustLII 2012).

3. Where does it occur? Fraud can happen at any level in an optometric practice and supply chain Range from false records or declaration to Medicare and Private Health Care fraud Therapeutic Prescription fraud Advertisement fraud Fair Trading fraud

4. Who does it impact? • Fraud impacts the optometric profession as a whole in regards to its reputations • Also impacts relationship between • Optical manufacturer suppliers, • Optometry practice and its staff • Private and Public sector health care, • General public • The above behaviour also pressures competition to do the same (domino effect)

5. Patient Fraud • Using another person’s Medicare or health insurance benefits, posing as the cardholder • Hard to trace as most practices don’t ask for photo identification for all new patients • Some knowingly ask for the use of friend or family member’s (Medicare and private health care) benefits to be used

6. Optometrist Fraud - Medicare • Medicare is Australia’s publicly funded healthcare system that allows Australian citizens and permanent residents to receive subsidised treatments from certain healthcare professionals such as optometrists (Department of Human Services 2013). • On the flipside, optometrists can also take advantage of Medicare and falsely bill consultations for financial gain (OCANZ 2010). Examples include: • Overcharging inappropriate amounts for consultations performed • Charging for consultations not performed

7. Medicare Investigation • Random and targeted auditing keeps compliance of such fraud at bay • Investigators for suspicious practices (Medicare Australia 2013).

8. Private Health Insurance Private health insurance includes organisations such as Bupa, Medibank Private, and HCF. These organisations provide cover for expenses incurred through illness or other health issues. Private health insurance provides benefits for members for medical costs that are incurred as a result of health issues and needs

9. Private Health Insurance Fraud • However there are increasing concerns that the current economic climate has increased the prevalence of private health insurance fraud • Some ways this can occur are: • Claiming for items that were not provided or required • Over-claiming for items to maximise benefits for patients • Claiming for persons not present at time of claim (Eddy, 2008)

10. Private Health Insurance Intervention • Optometry practices are being investigated by private health funds • Health funds review their own internal data to see if there are concerns that they can identify • If so, then they often hand the case over to a specialist investigator who makes contact with the practice and seeks to examine their records • If fraudulent activity is suspected, the investigator reports back to the fund which will decide if further action is indicated • If it is, then the fund will make contact with the practice to ask formally why a penalty should not be imposed. If the complaint is not sufficiently resolved then the fund will institute a penalty.

11. Fines and Penalties In the optometric industry, there are no standards or schedules of fines and penalties for fraudulent activities If a health fund or Medicare becomes aware of a fraud, they can seek to recover the monies that were wrongly claimed, and in serious cases can pose legal ramifications A disciplinary tribunal could impose a fine, place conditions on registration or, in major cases, de-register the practitioner. A court can impose fines or even impose a gaol sentence (OCANZ 2010) (Australian Government, ComLaw 1973).

12. Advertisement Fraud Due to current legislation and economic situation, more independent practices have adopted dynamic marketing to increase its turnover Most normal tactics offer discounts or loyalty bonuses with conditions attached. Other tactics include selling cheaper, lower quality goods to match the consumers’ budget Fair Trading NSW 2013 quotes that products sold from a registered business carries consumer guarantees regardless of warranty must: • Meet any extra promises made about performance, condition and quality, such as lifetime guarantees and money back offers; • Have spare parts and repair facilities available for a reasonable time after purchase unless you were told otherwise In the scope of modern optometric practice, new technology (e.g. OCT) has equipped practitioners with diagnostic tools, sometimes over-promising on the service and charging for tests that are not indicated

13. Therapeutic Endorsement • Prescribing drugs with no accreditation through another’s prescription pad. May be prevalent in: • Rural areas with limited availability and mostly non-therapeutically endorsed optometrists • Busy practices with optometrists who will find it difficult to complete an Ocular Therapy post-graduate course • Optometrists who do not find that undertaking this course it financially viable, or feel that they will not be working for much longer

14. Reporting Fraud Medicare’s fraud division, the Optometry Board of Australia, the Health Care Complaints Commission or the health fund concerned. Unless the fraud was extremely major you wouldn’t normally go to the police. (Medicare Australia 2013) (HCCC) It is an obligation for a health professional to report any fraudulent activity being performed if they become aware of such proceedings. If they fail to do so, they may also face penalties and prosecution as they have passively allowed future fraudulent activity to continue.

15. Conclusion Fraudulent activity still occurs in the optometric industry everyday This places strains on the entire optometric health care system and develops a nature of untrustworthy and unstable client base Optometrists can perform fraud against: • Medicare, Private Health funds, customers and patients Advertising fraud also impacts the optometric industry as it is a hybrid business of healthcare and retail operations. This means we must meet: • The standards and needs of healthcare (provided by the code of conduct for optometrists and; • The retail standards set by Fair Trading NSW (In this state) which can be tricky and sticky with certain patients and customers

16. References Medicare Australia 2013, Fraud, viewed 15 August 2013, http://www.medicareaustralia.gov.au/provider/business/audits/fraud.jsp Australasian Legal Information Institute (AustLII) 2012, HCCC v Ford [2012] NSW OPT1, viewed 18 September 2013,http://www.austlii.edu.au/au/cases/nsw/NSWOPT/2012/1.html Department of Human Services 2013, Medicare services, viewed 18 September 2013,http://www.humanservices.gov.au/customer/subjects/medicare-services Optometry Council of Australia and New Zealand (OCANZ) 2010, Competency in Optometry Examination Supplementary Materials for Candidates, viewed 16 August 2013,www.ocanz.org/component/docman/doc_download/17-supplementary-materials Eddy, J 2008, ‘Private Health Fund Fraud Under Investigation’, Private Healthcare Australia, 29 October, viewed 13 August 2013,http://www.privatehealthcareaustralia.org.au/news/media_releases/private-health-fund-fraud-under-investigation/ Australian Government, ComLaw, 1973, Medicare Australia Act 1973, viewed 16 August 2013, http://www.comlaw.gov.au/Details/C2008C00265/Html/Text#param64 Fair Trading NSW 2013, Consumer Guarantees, viewed 16 August 2013,http://www.fairtrading.nsw.gov.au/ftw/Consumers/Consumer_guarantees_warranties_and_refunds/Consumer_guarantees.page? Fair Trading NSW 2011, False and Misleading Representations, viewed 16 August 2013,http://www.fairtrading.nsw.gov.au/ftw/Consumers/Advertising_and_pricing/False_and_misleading_representations.page? Health Care Complaints Commission (HCCC), About the Commission, viewed 18 September 2013, http://www.hccc.nsw.gov.au/About-Us/About-the-Commission/About-Us