Private Health Insurers Accessing Full Medical Records in Audits

Private health insurers can look at clinical records during audits.

In short:

Health insurers can ask for a patient's notes to ensure the correct procedure was billed.

However, hospitals and health providers are concerned about insurers asking for full clinical histories.

Private health insurers are looking at patients' confidential medical information, which some call 'aggressive' audit practices.

Insurers can ask for a patient's notes to ensure the correct procedure was billed, as part of their agreements with patients and hospitals.

But hospitals and health providers say insurers have asked for full clinical histories, which is a concern.

This comes after concerns about health insurer Bupa's behavior and allegations of misuse of market power in the industry.

Insurers are auditing health providers.

A physiotherapist was audited twice by Bupa and was asked for the full clinical history of his Bupa patients.

Bupa has been criticized for its auditing practices.

The physiotherapist asked his patients for permission to release their documents, but two-thirds refused.

When he told Bupa, they said they wanted the details anyway, citing their agreement with the physiotherapist.

Experts say that when patients sign up for private health insurance, they agree to let their records be accessed during audits.

The physiotherapist was told by the regulator that he should not release the information without patient consent, but Bupa threatened him with penalties.

The situation was resolved after the physiotherapist went to the Commonwealth Ombudsman.

The physiotherapist said he almost gave up on the industry after the experience.

Bupa said they do routine audits to ensure claims are correct and customers are paying the right amount.

Bupa said they are committed to protecting customers' privacy and working with providers to resolve issues.

If there's a question about a claim, there are review and dispute processes in place, Bupa said.

Dentists report insurer overreach.

The Independent Dentist Network said dentists have reported health insurer overreach on audits.

A dentist was audited by a large insurer, who claimed the dentist had submitted questionable claims.

Dentists can be audited by private health insurers.

The insurer sent in auditors who were not qualified to review the dentist's patient histories.

The auditors reported back to the insurer and wanted some treatments reclassified.

The claim was reduced and ultimately dropped after negotiations and legal threats from the dentist.

The dentist was still traumatised by the experience and did not want to speak publicly.

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Concerns about auditor qualifications and their ability to assess complex medical cases have been raised before.

Bupa brought a court case against a Sydney ophthalmologist over a dispute on anaesthetics claims following an audit.

The ophthalmologist won the case, and Bupa was ordered to pay his costs.

The court noted that Bupa's audit did not involve an ophthalmologist with the necessary expertise.

The private health insurance industry has said that 'tough behaviour' is needed to keep premiums down.

Releasing patient notes without permission is illegal, according to a lawyer.

The lawyer said an insurer cannot write terms into a contract that violate the law.

Asking for patient notes outside an episode of care without permission should void the contract, the lawyer said.

Bashi Hazard says patient privacy is important.

Patient confidentiality is a serious obligation for healthcare providers, Dr Hazard said.

The implications of violating patient confidentiality are significant for individual providers.

The Australian Private Hospitals Association said some hospitals have experienced similar pressure from insurers.

The association's chief executive said hospitals have complained about 'rogue behaviour' from insurers.

Insurers want the patient's full medical history, which is a concern for hospitals.

The conduct is believed to be illegal, and hospitals have complained about the focus on minor technical issues.

Insurers are only allowed to look at hospital records with a chaperone.

Auditing is adding cost to hospital operations because they have to facilitate access.

It is hard to believe patients are happy about insurers looking at their medical records, the association's chief executive said.

The legality of some audits is less clear due to overlapping health laws.

Prudential standards require insurers to ensure payment integrity, and health insurance terms allow for auditing.

Brett Heffernan says hospitals are experiencing 'rogue audits'.

If hospitals don't provide information, insurers are threatening penalties, which is a concern.

Contracts need to be cleaned up to address these issues.

See more ABC coverage.

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