Being A Health Fund Provider: Your Responsibilities And Obligations
This article first appeared in the December 2016 issue of the AMT journal In Good Hands, and it seems timely to remind massage therapists of their responsibilities and obligations as health fund providers.
A reminder from the AMT Board
The AMT Board and past executives have worked hard to establish and maintain provider agreements with the various private health funds on behalf of AMT members. These agreements between AMT and the funds involve a mutual undertaking to honour the spirit and letter of the conditions as they are laid down.
A high percentage of AMT’s members maintain provider status with the health funds. Health fund recognition has helped to raise the profile of massage therapy in the community, moving massage from the margins into mainstream healthcare.
However, it is worth remembering that the privilege of achieving provider status and working as a healthcare professional also comes with a set of professional and ethical responsibilities. These responsibilities are comprehensively encapsulated in the AMT Code of Practice.
Standards of Care: Maintaining Clinical Records
If you are complying with the standards laid down in the AMT Code of Practice then you can be confident that you also meet the provider terms and conditions set by individual health funds. As a service provider for a specific fund, you should be aware that you are bound by the provider terms and conditions of that fund. It is crucial to keep abreast of your obligations. The AMT Board strongly recommends that you review both the AMT Code of Practice and the various health fund provider terms and conditions to ensure that you are operating in accord with expected standards.
The AMT Code of Practice is available via the AMT website.
The various health fund provider terms and conditions are available via the AMT website.
Maintenance of appropriate clinical records is particularly crucial for manifold reasons. Be aware that the health funds have the right to audit your practice at any time and may request copies of client files and treatment plans. Health funds can and do take action to recover funds from providers if the records they keep do not clearly show that rebatable, remedial massage has taken place. Sometimes this recovery of funds can amount to thousands of dollars’ worth of claims. The AMT Board has also commenced a program of audits of members to ensure that record keeping is in line with the standards in the Code of Practice.
Aside from the Code of Practice, AMT has made available useful resources to help you maintain appropriate treatment records. These include case history/intake forms and informed consent templates. These practice resources are available via the AMT website.
Say no to fraud
The exponential growth in health insurance fraud over the past five years represents one of the biggest threats to the advancement of our industry. The AMT Board takes an extremely dim view of members who compromise the provider agreements we have worked so hard to initiate and uphold by being slack or dishonest in receipting treatments.
The AMT Board has taken action to remove members who have committed insurance fraud.
The provider numbers issued to you by AMT and the individual funds are yours and yours alone. They are issued on the understanding that you will continue to honour your basic obligation to be ethical and honest in your dealings with your clients and the third party insurers that subsidise the cost of client treatments with rebates.
The following are all examples of insurance fraud and will not be tolerated by the AMT Board:
- Allowing another therapist to use your provider number(s)
- Pre-signing receipts for use by other therapists
- Using another therapist’s provider number for a treatment performed by you (for example, when you are not registered as a provider with a particular fund but a colleague is)
- Issuing receipts for a service and/or treatment you did not provide.
- Backdating receipts
- Falsifying any information on a receipt (for example, issuing a receipt in the name of another family member when a client has reached the limit of their own claims)
- Splitting receipts – writing receipts for two half-hour treatments when the treatment was for one hour.
The dishonest practices of a single member or group of members deeply compromise the good relationships AMT has built with the private health funds. AMT’s credibility as a professional, representative body is on the line every time a member (or members) fiddle the system.
Sophisticated fraud detection software now gives the funds an unprecedented capacity to crosscheck and spot inconsistencies in receipting. If a client is pressuring you to do the wrong thing and falsify receipts, say no. If a colleague is pressuring you to do the wrong thing and falsify receipts, say no. If an employer is pressuring you to do the wrong thing and falsify receipts, say no.
Read AMT’s receipting standard so you are aware of your professional and ethical responsibilities as a member of AMT and a health fund provider.
AMT’s goal is to strive for recognition and acknowledgement of our professional expertise. However, if we are to be taken seriously as professionals, we must be serious about our professionalism.
Health insurance fraud is dishonest and damaging behaviour that threatens to drag the entire industry back twenty years.
Please do the right thing by AMT, by the private health insurers, by your colleagues, by the industry at large and by your clients.