FRAUD IN OPTOMETRY

1. FRAUD IN OPTOMETRY Eric Pan (#6) David Kim (#17) Simon Lim (#28) Lisa Ma (#39)

2. Definition • “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) Who Commits the Fraud? • May be performed by the optometrist, staff or patient • Examples of fraudulent behaviour within the optometric profession include • Medicare fraud • Private health insurance fraud • Misconduct or false reporting in research • Tax evasion • Malingering • Advertising fraud • Therapeutic Prescription fraud • Fair Trading fraud

3. Stages That It Can Occur: Fraud Triangle Image from: Montgometry, DD.  Beasley, MS. Menelaides, SL. Palmrose, ZV (2002) Auditors’s New Procedures for Detecting Fraud, J Accountancy, accessed 11 September 2013 <http://www.journalofaccountancy.com/Issues/2002/May/AuditorsNewProceduresForDetectingFraud.htm>

4. Impact Of Fraud • Impacts beyond the individuals involved, to the wider community • Also impacts relationship between • Optical manufacturer suppliers • Optometry practice and its staff • Private and Public Sector health care • General public • Also pressures competition to do the same (domino effect) • Decreased productivity, depletion of resources and misallocation of government benefits • Unfair business environment for competitors • Ethical misconduct in research Image from: http://msdn.microsoft.com/en-us/library/ms954628.aspx

5. Medicare Fraud • Patients can claim optometric services through Medicare, which may involve bulkbilling or partially subsidised services under Medicare’s safety net • Estimated to be approximately $2-3 billion yearly • Examples • Up-coding the services they provide • Billing services never provided • Repackaging/increasing their fees to maximise the amount they claim under the safety net

6. Private Health Insurance Fraud • Optometrists were among the providers who recorded the highest amount of complaints • Current economic climate has increased the prevalence of private health insurance fraud • Hold a significant benefit for consumers (reduction in the ‘gap’) • Pressure on the staff and optometrist • Change in patient base due to ‘new’ reputation • Examples • Up coding or miscoding claims • Combining or using other peoples’ health insurance • Splitting claims • Claiming items that were not provided or required

7. Detection of Health Care Fraud • Medicare • Random compliance audits throughout the year • May use targeted compliance audits • Can be reported directly to the Australian Government Services Tip-Off Line (131 524) • Private Health Funds • Systematic: data mining and algorithms • Internal: scrutinised by the fund, and audits of the claims • External: reported by the public may report fraud, competitors, ex-employees or mystery shoppers • Reported to the fund directly or Private Healthcare Australia.

8. Consequences • No standards or schedules of fines and penalties for fraudulent activities • Seek to recover the monies that were wrongly claimed, and in serious cases can pose legal ramifications • Criminal offence (NSW Crimes Act) • 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, ComLaw1973) Image from: Givney, L 2012, Fraud Awareness, HCF

9. Advertisement Fraud • Optometry has responsibility for advertising as both a retail business, and a health care provider • Adopted dynamic marketing to increase its turnover • Regulating bodies for advertising • Examples • OPSM vs. Specsavers (2013) “Better Frames, Better Lenses, Better Fit”  • Optometric use of Dr. • New technology (e.g. OCT), may result in over-promising on the service and charging for tests that are not indicated • Cases of fraud can be reported to the Australian Health Practitioner Regulation Agency (AHPRA) • Disciplinary mechanisms • Fair Trading NSW (2013)

10. Misconduct in Research • “Fabrication, falsification, plagiarism or deception in proposing, carrying out or reporting the result of research, and failure to declare or manage a serious conflict of interest” • Impact upon • Those receiving the treatment • Health of the population • Examples • Purposely creating research data • Recruiting and consenting patients without ethics approval • Failure to advise the patient on what is involved during the duration of the research

11. Tax Evasion • To gain financial benefit • May break the law to avoid paying their fair share or try to claim funds or other payments they are not entitled to • Examples • Obtaining false leases for optical equipment • Incorrect tax returns • False reporting of income • Hiding assets.  • Liable to penalties • Calculated using a statutory formula or in multiples of a penalty unit ($170) • May be administrative, civil or criminal • Interest charges can apply regardless of penalties

12. 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

13. Malingering • Deliberate act that exaggerates symptoms of illness/injury to mislead the examiner for a desired purposes • Reliant on subjective responses • Battery of objective tests to detect these individuals • Tests for total blindness • Nystagmus • Pupillary reflexes • Tests for unilateral blindness • Eight dioptre prism in front of the alleged blind eye • High plus lenses in front of the good eye whilst reading

14. Reporting Fraud • Involves • Medicare’s fraud division • Optometry Board of Australia • Health Care Complaints Commission • Health fund concerned • Police are involved in the serious cases • Obligation for a health professional to report any fraudulent activity being performed if they become aware of such proceedings • Otherwise, they may also face penalties and prosecution as they have passively allowed future fraudulent activity to continue.

15. References