AXA PPP healthcare Provider Investigations – 2014 Paul Francis

1. AXA PPP healthcareProvider Investigations – 2014Paul Francis

2. Honest or Not?...

3. Agenda… • Cost of Fraud • Types of Fraud • Health Insurers Counter Fraud Group • Fraud Controls • Horror Stories • Recent Cases • Any Questions?

4. About me… • 1975 - 1997 Royal Air Force Policeman • 1997 - 2001 Electronic tagging of prisoners • 2001 - 2014 AXA PPP healthcare • Accredited counter fraud specialist • Manager of the Provider Investigations team • Member of the Health Insurance Counter Fraud Group

5. Trust me, I’m a doctor?...

6. BBC News … • Fraud - including scams, online theft, insurance cheats and tax fraud - costs the UK £30bn a year, according to an official estimate. The Insurance Fraud Bureau estimates the cost of organised motor insurance claims alone is £392m each year (Sep 2014) • Insurance fraud: £2bn • The National Fraud Authority (NFA) has calculated the figure for the first time and said it equated to £621 per adult in the UK. • Unfortunately, fraud takes place across the financial services sector. This includes AXA and we have a responsibility to protect our customers.

7. BBC News 24 March 2014… • NHS is losing more than £5billion a year in fraud, with cash being stolen to fund stud farms, ghost employees and private school fees. • Fraudsters are siphoning off taxpayers’ money that could otherwise be spent on patients’ healthcare needs including expensive cancer drugs, according to an alarming report.

8. BBC News 25/5/12… • Head of security in £2.5m Lloyds fraud charge • A FORMER HEAD OF SECURITY AT LLOYDS BANK HAS BEEN CHARGED IN CONNECTION WITH AN ALLEGED £2.5M FRAUD by SUBMITTING FALSE INVOICES TO CLAIM PAYMENTS. • AT THE TIME SHE WAS WORKING AS HEAD OF FRAUD AND SECURITY FOR DIGITAL BANKING. JAILED FOR 5 YEARS.

9. Types of Fraud… • A misrepresentation of the facts with the intention of making a gain or causing a loss. • Three main offences: • Section 2 – Fraud by false representation • Section 3 Fraud by failing to disclose information • Section 4 – Fraud by abuse of position

10. Types of Healthcare Insurance Fraud… • Policyholder – non disclosure, provider collusion, false travel claims • Provider – unbundling, up-coding, over-servicing, phantom treatment • Sales – invented members for group discounts/improved agency fees • Staff – expenses, misuse of company assets

11. Types of Provider Fraud… • Up-coding charging for a service/procedure code that is more expensive than the actual procedure that was carried out • Unbundling – the breaking down of a procedure into its separate parts and charging for each one • Duplicate billing – the process of systematically invoicing for the same treatment, either to different or the same payees • Over servicing – carrying out more treatments or tests than is clinically indicated or necessary • Misrepresentation – includes phantom billing, withholding relevant information as well as presenting inaccurate or false information with the intention to defraud

12. H.I.C.F.G… • Health Insurers Counter Fraud Group • 23 health related insurance companies including 10 largest Private Medical Insurers including Cash Plan Health Insurers, International insurers • Intelligence –provides a network and technical platform to share intelligence and in order to prevent and detect fraud within healthcare • Best Practice – runs an Accredited Counter Fraud Training course • Global Healthcare Counter Fraud Network – Founder member, Global summit • Partnership – Formal relationships with : • Domestic – NHS Counter Fraud Services, City Of London Police, Insurance Fraud Bureau and Insurance Fraud Investigators • International – health fraud investigation bodies in U.S.A, Europe, Canada, Australia, Middle East, South East Asia, and South Africa

13. Health Fraud Hub…

14. Our Database…

15. Fraud controls… • Objectives: • Enhance our systems to provide more accurate advice to PAs when pre-authorising claims • To advise when potentially suspicious information is given by a customer or provider • To capture better information on what treatment our customers are having • Why are we doing this? • To provide PAs with more information on the claim they are pre-authing • To identify where customers are trying to get something paid which is not eligible • To save AXA money and ensure our honest customers are not penalised with higher premiums because of the handful of providers or customers who are trying to catch us out

16. Horror stories… Tuesday 18 January, 2000 Doctor 'offered sex as a treatment' • “A Harley Street doctor persuaded a woman to have sex three times as a form of therapy for her fear of intercourse, the General Medical Council (GMC) has heard.”

17. Horror Stories… BBC News: July 2000 Richard Neale: • Struck off in Canada –patient dies in childbirth • Neale was struck off in 2000 by the GMC. Had been treating our members at Portland hospital. • “Richard Neale's turbulent career has left a trial of misery stretching back 20 years. The gynaecologist, who has been found guilty by the GMC of 34 charges of failing to provide appropriate care to patients and lying about his qualifications, was born and trained in the UK”

18. “The Butcher”… • Oct 2000 - Police Investigated claims that a notorious gynaecologist faked his own death to escape prosecution for rapes and sexual assaults. • Rodney Ledward was branded 'The Butcher' and struck off after 500 women complained he had botched operations over 16 years of appalling incompetence. • Many were scarred for life and six were said to have died as a result of his blunders. Scores more patients claimed he had sexually assaulted them in hospital. • Allegedly died of cancer in 2000

19. Celebrity surgeon?... • Surgeon to the Stars suspended over insurance irregularities • Nigella’s “force for good” breast cancer surgeon on 19 fraud charges

20. Horror Stories…

21. Justice, perhaps?... • Adelaide News – Jan 2011 • A MENTALLY-ILL doctor accused of 19 counts of fraud and ruled unfit to practise is working at Adelaide's Lyell McEwen hospital where he has botched an operation and attempted to conduct surgery while under the influence of drugs, State Parliament has heard. • "I also understand that Dr Sacks and the hospital are currently being sued by a patient who alleges that Dr Sacks was going to proceed with surgery whilst under the influence of either alcohol or medication," Dr McFetridge said

22. Harley Street surgeon… • Huge private clinic in Harley St • Evidence from 4 top specialists in field of fraud concluded that patients are being mistreated. • GMC hearing due Dec 10 • Voluntary erasure – Nov 10 • De-recognised – Feb 11

23. – 17 Nov 2011… • GMC criticised for letting doctors retire to avoid malpractice claims • 17 Nov 11; scores of doctors accused of serious malpractice have avoided adjudication hearings by taking early retirement. Health insurers and patient safety groups have criticised the GMC for allowing 69 doctors to take “voluntary erasure” instead of facing investigations into their fitness to practise. • Simon Peck, AXA PPP’s head of medical investigations and advice says: “Voluntary erasure allows a doctor to relinquish registration as a medical practitioner without an admission of guilt in return for the charges against them being dropped. It’s very dangerous to have a system where the regulator allows people to withdraw but doesn’t look at the underlying issues.”

24. BBC News 25 March 2014… • Anger at sacked Kent surgeon • Cancer patients left in pain by botched operations at the hands of a Kent surgeon have reacted with anger after he was allowed to remove himself from the medical register on grounds of ill health. • Dr ********* was sacked in 2007, after scores of complaints, but never appeared before a disciplinary hearing because he was too ill. A Medical Practitioners Tribunal Service (MPTS) granted him "voluntary erasure"

25. My GP!… • Dr Antony Collis • Doctor abused children during 25-minute 'counselling' sessions • 58-year-old carried out 'indecent examinations' on five under-14s • Married GP also took indecent images of the children • Jailed for 8 ½ years

26. Pathology Lab?...

27. Our Recent Case Load… • A horse riding stables to which we paid over £300,000 for pathology tests. • A fake cancer treatment offered at a cost of £10,000 to the terminally ill. • A healthcare professional, (not recognised by us) renamed a pressure study of the sole of the foot as Motion Realtime Imaging. He told customers that this was also known as MRI and proceeded to raise £70,000 for MRI scans- at rates of around £700 – (a foot pressure study would command probably £25).

28. International case… • Corporate policy with many “employees” • Set up electronically from Canada • Claims were submitted from clinics in the Middle East, all with valid websites, however they were all fake • Other insurers also targeted • Total losses to date – over £1.5 million

29. To conclude… • In 2012/13 we have recovered over £1+ million in fraudulent payments. In 2013/14, that figure rose to £2.2 million and in some cases we have ceased dealings with rogue providers. • A leading management consultant in the PMI industry has commented that in his travels across the UK, he has noted that AXA PPP healthcare are by far the most active company in the counter fraud arena.

30. Experts?...

31. Business details… • Paul Francis, Provider Investigations manager • Address: International House, Forest Rd, Tunbridge Wells, TN2 5FE • E Mail: paul.francis@axa-ppp.co.uk • Mobile: 07775014608 • Office: 01892 612931