Fighting fraud with Medibank

Fraud is bad for everyone

Fraud isn't about people making honest mistakes. Fraud is a calculated attempt to get things that you wouldn't otherwise be entitled to from the health system.

This affects all of our 3.8 million members by undermining systems and pushing up costs. We take fraud very seriously, whether it's by members or by treatment providers, like hospitals, doctors or other practitioners.

What does fraud look like ?

Fraud has many forms. Health insurance fraud could happen through claiming for treatment or services that haven't been provided, using someone else's Medibank card, or providing false information or documents. Fraud through claim abuse can be carried out by individuals, or by groups working together.

Member fraud can mean:

• Making a claim for something that hasn’t been provided.
• Claiming a benefit you’re not entitled to.
• Using a fake name to get a membership or claim benefits.

Provider fraud can mean:

• Invoicing for different item numbers for financial gain.
• Charging members for something that isn’t clinically necessary.
• Claiming benefits for something done by a different provider.
• Claiming for services or products that weren’t provided.

How does Medibank combat fraud?

Our investigations team detect fraud in a number of ways, from using sophisticated technology to identify unlikely treatment patterns to training our staff to spot suspicious behaviour. We target fraud through claims verification, focused intelligence and formal investigations.

How can members help?

• Keep your membership card safe and your information confidential.
• Check that you have been billed correctly and for the right item numbers.
• Tell us immediately if you see anything suspicious in your claims history.
• Make a report to tell us about anything suspicious.

How can providers help?

• Make sure you’re using the right item numbers on every claim.
• Let us know if anyone tries to make improper claims for benefits.
• Remember that you’re personally responsible for claims using your provider number.
• Properly train staff in making claims and using your provider number.
• Make a report to tell us about suspicious behaviour.

Making a suspicious activity report

We know that making a report can feel a bit scary, but you’re doing the right thing for all of our members. If confidentiality is a concern, you don’t even need to give us your name. The more information you can give us, the more likely we’ll be able to do something to prevent further fraud.