AXA PPP healthcare
Provider Investigations – 2014
Paul Francis
Honest or Not?...
Agenda…
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Cost of Fraud
Types of Fraud
Health Insurers Counter Fraud Group
Fraud Controls
Horror Stories
Recent Cases
Any Questions?
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
Trust me, I’m a doctor?...
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.
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.
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.
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
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
Types of Provider Fraud…
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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
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
Health Fraud Hub…
Our Database…
Fraud controls…
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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 preauthing
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
Horror stories…
Tuesday 18 January, 2000
Doctor 'offered sex as a treatment'
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 “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.”
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”
“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
Celebrity surgeon?...
 Surgeon to the Stars suspended over insurance
irregularities
 Nigella’s “force for good” breast cancer surgeon on
19 fraud charges
Horror Stories…
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
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
– 17 Nov 2011…
 GMC criticised for letting doctors retire to
avoid malpractice claims
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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.”
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"
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
Pathology Lab?...
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).
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
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.
Experts?...
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