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Health fund claims for family members

27 September 2021

Third party payment mechanisms are commonplace in contemporary dental practice. Dr Mike Rutherford, Senior Dentolegal Consultant at Dental Protection, looks at why it is important to understand what this really means

 

Dr X’s father booked in for a check-up with his son the week after he had graduated from dental school. Dr X had also treated his partner in the clinic while he was a dental student and arranged to continue seeing her in his new private clinic upon graduation. Dr X had been treating both his parents and his wife ever since.

Dr X was therefore astounded and confused when he received a letter from his private health insurer stating that the fund rules and his HICAPS agreement with the fund prohibited claims made as a result of treating family members. The letter further demanded repayment of $2,800, which amounted to the claims made over the last three years for service rendered.

Dr X phoned Dental Protection, explaining that he had provided all the treatment claimed and had recorded this in his notes using appropriate item numbers. He had in no way acted fraudulently. Regretfully, however, most health funds prohibit these claims regardless of accuracy. Equally as unfortunate for Dr X, as an associate dentist on commission the amount demanded by the health fund far exceeded the amount Dr X had been paid for the services.

Dental Protection assisted Dr X formulate a reply to the health fund, declaring the integrity of his claims and seeking leniency in this instance, as well as leave to claim for future treatments of family members. The health fund agreed to a somewhat reduced repayment sum but did not agree to future claims being made for Dr X’s family members.

Learning points

  • Understand the rules of the third parties from whom you make a claim.
  • Read your HICAPS agreement.
  • Consider the appropriateness of any claims made, regardless of who they are for.
  • Seek advice if you receive a letter from a health fund or Medicare regarding an issue with your claiming.

These case studies are based on real events and provided here as guidance. They do not constitute legal advice but are published to help members better understand how they might deal with certain situations. This is just one of the many benefits Dental Protection members enjoy as part of their subscription. 
For more detailed advice on any issues, contact us

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