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) 1 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 • Impacts relationship between • Optical manufacturer suppliers • Optometry practice and its staff • Private and Public Sector health care • General public • 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 bulk billing or partially subsidised services under Medicare’s safety net • Estimated to be approximately $2-3 billion 2,3 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 Images from: http://www.updateyouraddress.com.au/update.html http://anthonyliska.com.au/optometrist/medicare-bulk-billing/

6. Private Health Insurance Fraud • Optometrists were among theproviders who recorded the highest amount of complaints4 • 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 Image from: http://crapmamma.com/tag/private-health-insurance/

7. Detection of Health Care Fraud • Medicare • Random compliance audits throughout the year 1 • May use targeted compliance audits • Can be reported directly to the Australian Government Services Tip-Off Line (131 524) 5 • Private Health Funds • Systematic: data mining and algorithms 6 • Internal: scrutinised by the fund, and audits of the claims 6 • External: reported by the public may report fraud, competitors, ex-employees or mystery shoppers 6 • 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. • Courts can impose fines or even impose a gaol sentence 7 Image from: Givney, L 2012, Fraud Awareness, HCF

9. Advertisement Fraud • Responsibility 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) • Disciplinary mechanisms • Fair Trading NSW (2013) • Reported to the Australian Health Practitioner Regulation Agency (AHPRA) 8

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” 9 • Impact upon • Those receiving the treatment • Health of the population • Examples10 • 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 • Avoid paying their fair share or try to claim funds or other payments they are not entitled to 11 • Examples • Obtaining false leases for optical equipment • Incorrect tax returns • False reporting of income • Hiding assets • Liable to penalties 12 • Interest charges can apply regardless of penalties Image from: http://www.topnews.in/business-news/income-tax

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 Image from: http://blog.optx2020.com/45/causes-fixes-for-dry-eyes

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 13 • Nystagmus • Pupillary reflexes • Tests for unilateral blindness 13 • Eight dioptre prism in front of the alleged blind eye • High plus lenses in front of the good eye whilst reading Image from: http://www.mumsgone2aus.com/2010/11/23/before-school-check-provided-by-early-childhood-health-centres/

14. Reporting Fraud • Involves • Medicare’s fraud division 14 • 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. Conclusion • Fraudulent activity still occurs in the optometric industry everyday • Places strains on the entire optometric health care system • Develops a nature of untrustworthy and unstable client base • Optometrists can perform fraud against: • Medicare, Private Health funds, customers and patients • Can be tricky and sticky with certain patients and customers • Further action needs to be taken

16. References • Medicare Australia 2013, Fraud, Australian Government Department of Human Services, accessed 7 July 2013, http://www.medicareaustralia.gov.au/provider/business/audits/fraud.jsp • Tippet, G 2004,  Fraud on Medicare ‘costing billions’, The Age, accessed 17 August 2013 http://www.theage.com.au/articles/2004/09/05/1094322642694.html • Webber, T (2012) What is Wrong with Medicare? Med J Aust, 196 (1): 18-19 • Private Healthcare Australia 2008, Private Health Fund Fraud Under Investigation, accessed 17 August 2013 http://www.privatehealthcareaustralia.org.au/news/media_releases/private-health-fund-fraud-under-investigation/ • Department of Human Services 2012, Annual Report 2013-2015, Australian Government, accessed 11 September 2013 http://www.humanservices.gov.au/spw/corporate/publications-and-resources/resources/compliance-program-plan-2013-15.pdf • Givney, L 2012, Fraud Awareness, HCF • 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 • Optometry Board of Australia n.d., Guidelines for Advertising of Regulated Health Service, accessed 11 September 2013http://www.optometryboard.gov.au/documents/default.aspx?record=WD10%2F2671&dbid=AP&chksum=3ZybCL%2B%2FcDGSrOpZ72CxZA%3D%3D • National Health and Medical Research Council 2007, Australian Code for the Responsible Conduct of Research, Australian Government http://www.nhmrc.gov.au/_files_nhmrc/publications/attachments/r39.pdf • Elliot, P 2009, Research Misconduct and Fraud Policy, NHS Western Cheshire, Chester • Australian Taxation Office 2013, Tax Evasion and Crime, Australian Government, accessed 10 July 2013, http://www.ato.gov.au/General/Tax-evasion-and-crime/ • Australian Taxation Office 2012, Penalties and Interest, Australian Government, accessed 11 September 2013 http://www.ato.gov.au/General/Correct-a-mistake-or-dispute-a-decision/In-detail/Instructions-and-guides/Penalties-and-interest/?default=&page=1#Overview • Gandhi, R 2012, Malingering in Ophthalmology, Medscape Reference, accessed 12 July 2013, http://emedicine.medscape.com/article/1472467-overview#showall • 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