61 My Battle to Make the Health Insurers Obey the Law Part 14: 16 October 2024

I was disturbed by discovering HCF had refused to pay for Margaret’s Lift treatments because of active refusal to obey the law, rather than ignorance. 

Margaret was dying from cancer and our health insurer ignored the law requiring it to pay for the only non-invasive treatment that had slowed the spread of her cancer.  

At the patient support meeting on 6 February, one patient had recounted going to HCF Marion - an Adelaide suburb - to lodge a claim for a Lift treatment.  The HCF employee had tried to enter the claim in the computer system but the computer had refused to accept lodgment of the claim.  The Branch Manager had asserted very firmly that Lift was not a hospital and that the claim would not be accepted for assessment by HCF,

I wondered if I would have a similar experience if I also tried to lodge a claim at HCF Marion, so I decided to find out. 

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I gave my HCF membership card plus 3 pages of documents itemising Margaret’s treatment at Lift on 10 February 2022.  I gave a copy of our receipt from Lift verifying that the account had been paid on 10 February.  I asked for reimbursement by HCF of our health insurance entitlement.

The HCF employee was unable to enter the claim into the system.  He was clearly puzzled that he was unable to submit the claim for processing and said he would need to speak to his Manager.  The Manager - Rachel Harwood - then appeared.

Rachael said that she had had extensive discussions about claims from Lift Cancer Care with the Hospitals area of HCF and she had detailed knowledge of issues concerning claims for treatments by Lift.

When I asked what prevented submission of a claim, Rachael said that HCF would not permit any Lift claims to be submitted through the normal system.  When I asked how I could submit the claim for HCF processing, she said that if I wanted, she could accept the claim personally and send it to the Hospital Claims area.  She stressed this would be a waste of time because the claim would be rejected.

When I asked why the claim would be rejected, Rachael said that “Lift Cancer Care Services is not a hospital”.

When I said that to my knowledge, Lift Cancer Care Services was a fully accredited hospital, Rachael repeatedly said that “Lift Cancer Care Services is not a hospital”.  She repeated this at least four times.

Every time Rachael denied that Lift Cancer Care Services was a hospital, I contradicted her.  I said what she was saying was untrue and that Lift was a fully accredited hospital. 

When it became clear that I would not accept the assertion that Lift was not a hospital, Rachael claimed that in any event the invoice could not be processed because the “item number on the invoice is not a Medicare scheduled item.” 

I asked Rachael to explain exactly what she meant by this statement and wrote down exactly what Rachel said on the envelope containing the paperwork for the claim.  Racheal watched while I wrote down exactly what she said on the envelope.  I wrote this. 

“Item number in invoice is not a Medicare scheduled item.  Item 37 is not a Medicare number, is an exercise of physio class.  Lift is not a registered hospital.

 I then terminated the discussion. 

Rachael was adamant and rejected anything which contradicted what she was saying.  At this point I asked for a HCF print out of the details of all services detailed in my member account from 1 January 2021.  She queried whether I wanted ALL claim details, asking if I wanted claims for items such as dental.  I stressed I wanted a complete print out of all claims of any description from 1 January 2021 onward.  Rachael said that the Branch could not provide this information and that she would request that it be provided by a different area of HCF.  It would be mailed to me and take about a week.

Rachael certainly became agitated and was visibly annoyed when I said she was wrong in claiming that Lift Cancer Care Services is not a hospital.

I have no doubt that Rachael deliberately lied to me about both the status of Lift as a hospital and about Item 37.  I have no doubt Rachael was aware that she was lying to me that day.

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Hospitals in South Australia must be licensed by the South Australian Health Department.  Once the South Australian licence has been granted, the South Australian Health Department tells the Australian Health Department that the licence has been granted.  The Australian Health Department then issues a “Provider Number” under the Private Health Insurance Act.  The Provider Number issued by the Australian Health Department to Lift Cancer Care Services is 0067230T”.  The approved Provider Number was written in the top left hand corner of page 1 of the National Private Health Patient Hospital Claim Form that I tried to lodge with HCF that day.

The Australian Health Department publishes this information about Medicare Item 37. 

Medicare Benefits Schedule - Item 37 Level C Professional attendance by a general practitioner (not being a service to which any other item in this table applies) lasting at least 20 minutes, including any of the following that are clinically relevant: a)     taking a detailed patient history; b)     performing a clinical examination; c)     arranging any necessary investigation; d)     implementing a management plan; e)     providing appropriate preventive health care; in relation to 1 or more health-related issues, with appropriate documentation. Category 1 – PROFESSIONAL ATTENDANCES 37  Group A1 - General Practitioner Attendances To Which No Other Item Applies Subheading 3 - Level C Professional attendance by a general practitioner (other than attendance at consulting rooms or a residential aged care facility or a service to which another item in the table applies), lasting at least 20 minutes and including any of the following that are clinically relevant: (a) taking a detailed patient history; (b) performing a clinical examination; (c) arranging any necessary investigation; (d) implementing a management plan; (e) providing appropriate preventive health care; for one or more health-related issues, with appropriate documentation-an attendance on one or more patients at one place on one occasion-each patient.

 I have quoted the Health Department information about Item 37 in full.  Although I was not familiar with the Medicate item numbers, I am certain Rachael Harwood as Manager of HCF Marion was intimately acquainted with Medicare Item numbers.  It is inconceivable that she did not know Item 37 was a valid Medicare Item number.

My visit to HCF Marion left no room for doubt.  

HCF had instructed its staff to lie about Lift Cancer Care Services.  HCF had knowingly decided to break the law and it had knowingly instructed its staff to lie about the validity of claims for treatments by Lift.

HCF – and presumably Teachers Health and NIB – were actively involved in a criminal scam.