MY STORY

My

Health Insurance Claims

PART C: (Please read Part A and Part B first)

 

Evidence that supports my Health Insurance Claims. 

 

How much incompetence, dishonesty, and bullying do we put up with, in OUR health system? 

 

If you are reading this, you may have experienced a bad faith health insurance episode. I invite you to read on. The first distinction I would like to make is that you are dealing first and foremost with an insurance company, not a health company.

 

This may explain, why there is so much confusion and feelings of being rejected, angered, frustrated and ignored within private health insurance. The fox seems to be in charge of the hen house. 

 

Let’s face it, the sad reality is that insurance has taken over our health system. 

 

  • Private Health Insurance has taken over the private healthcare sector where caring practitioners service the community. It is also a place where health innovation should prosper.

  • The National Disability Insurance Scheme (NDIS) is an insurance model that blankets the vulnerable disability sector. 

  • When you go to our public hospitals you are treated preferentially if you are in health insurance. Why, because the hospital gets paid, by the insurance company. Clinical care is being pushed back due to financial motives.

  • Then there’s a whole other scenario with claims in the Workers Compensation and Motor Vehicle Insurance sectors. This is not my foremost area of expertise. When I left my worker's compensation practice, I was still owed thousands of dollars of unpaid invoices, which I never received. 

 

I assure you, it is not all that it seems, as I, unfortunately, discovered. Read on. 

 

My dream was to help the most vulnerable people in our community and address the health issues of our burgeoning aging population. In particular, I treated conditions including but not limited to things like arthritis, osteoporosis, neurological conditions, post-op rehab, back/neck issues, falls and frailty issues, also conditions like diabetes, heart disease, and pulmonary conditions to name a few. I also saw many intelligent people in my facility who realised that the best insurance there is for your health, is to be proactive and take care of your own health.  

 

To achieve my dream, I founded a medically orientated clinical exercise and rehab facility on the Lower North Shore in Sydney. It won multiple awards CLICK HERE, including the best overall business in the area. The service was commemorated by Mr. Abbott, the local member and Federal Health Minister at the time. For those of you reading outside of Australia, he later became the Prime Minister.

 

I believe I was one of the first Physiotherapists in Australia to develop a private Group Physiotherapy practice and my commitment and vision were pure. Spreading healing energy has no borders and we were lucky to secure trademarks in various countries. Most of my work was with the 50s plus clients, however, the ultimate ambition of the service, was to include treating spinal cord injured people, in the hope that some of them would walk again when stem cell breakthrough research advanced. This ambition was significant and it was the intention to partner up with a larger health company to maximise the business growth and develop the resources to treat anybody, with any rehabilitation need, no matter how difficult. An ethical medical company that puts patients in balance with profit.

 

Health insurance primarily works because young people with minimal health needs subsidise older people with many expensive medical needs. I question if the Health Fund (HF) values its older members or perhaps sees them as a burden. We need to stop and ponder, that a society can be judged by the way it looks after its elderly and disabled. An opportunity, to dig deeper and be creative with solutions to validate and care for our seniors.

 

Helping others was my calling and I answered the call, of course, surrounded by an amazing team, my staff. I attended the Christopher Reeves Gala Dinner when he visited Australia to raise money for spinal cord injury research. I night I will remember including the luck to meet Bob Carr there. He was putting a lot of attention to spinal cord injury healthcare at the time. Well done Mr. Carr. I was also making connections to exo-skeleton innovators too, for example, Monte Reed in the USA, who received a grant from NASA. 

 

Later, our business raised $10,000 CLICK HERE through kind donations from clients and community members for the 2008 Australian Paralympic team. A great team effort. This was at a stage when we were struggling as a small business ourselves.

 

I hope you are starting to see the wholesome context in which the business was being created. Our values were integrity, communication, teamwork, service, and fun. These values were compromised by a health insurance company (HF) as you will see in my story below. It describes the unfair treatment by (HF), which eventually forced me out of my business. I was compelled to share it with you, all is revealed below.

 

For legal reasons, I am unable to disclose the insurance company's name, my previous business name or some peoples names in the story. On this website, I have called the health fund (HF) to keep it simple. All attempts to hide the name has been made, any deliberate revealing of the name has been avoided. 

My 7 Health Insurance claims exposed:

 

Claim # 1: Incompetence and Discrimination

Claim # 2: Differences within the Industry 

Claim # 3: Misappropriation or Manipulation 

Claim # 4: False Facts

Claim # 5: Intimidation and Bullying

Claim # 6: Authority angst

Claim # 7: Compensation Required

 

Claim # 1: Incompetence and Discrimination

 

  • To obtain answers to questions, the entities to ask are health funds, associations, and colleagues.

        My experience was poor. CLICK HERE. They simply did not respond. 

 

  • Health fund (HF) did not provide any substantial rules, interpretations, guidance or productive feedback to my many attempts to seek guidance on Group Physiotherapy for 8 years. I wrote many letters. To this day, at the time of this website creation, I do not understand why information was withheld. Was it incompetence or was it intentional? Note that one of the later letters that I wrote, volunteers to help (HF) write up Group Physiotherapy rules with health fund (HF). I heard nothing back.

        CLICK HERE<< MUST READ 

 

  • Surprisingly a former (HF) very top senior staff member stated in an email on the 21st of February, 2014 that "In summary, wherever we have received correspondence, we have responded". This is obviously false. 100% false.

        The fish stinks from the head down. 'Jody' can't supply any evidence for specific Group Physiotherapy

       correspondence prior to the 16/9/2013, when asked and at the time of writing and ignores my emails.

       The APA CEO has been enlisted to obtain copies of these apparent letter 'responses', but repeated requests          to (HF) have been fruitless. Why, because they don't exist. A blatant cover up of either incompetence or 

        unsavory activities. Both are unhelpful to practitioners or patients.  

  • My Group Physiotherapy service underwent an onsite audit on the 16/9/2013, by health fund (HF). 40 days later, on the 25/10/2013, the health fund (HF) then released widespread industry educational material on Group Physiotherapy. 

        CLICK HERE<< MUST READ

  • Too late for me. Begs the questions, why was I isolated and targeted from the whole industry and audited before (HF) released their information. As far as I know, I was the only one audited to this degree for Group Physiotherapy prior to the 25/10/2013 letter, that's why I say I was clearly discriminated against.

      

  • I ended up writing to the Private Health Insurance Ombudsman (PHIO) and the health fund (HF) CEO expressing my disappointment of the poor communication by (HF) and my struggles to find out information if they don't respond. CLICK HERE

  • I find it interesting that when I went back through my initial (HF) email trail, it seems that all my 'specific to me' initial contact points from (HF) were from disciplinary roles. Multiple Provider and Claims Compliance Officers. This included a 3-minute onsite visit, patient notes review, then onsite review. CLICK HERE. Much later and more importantly after my onsite audit, too late for me, was first 'direct contact' with the Ancillary Benefits Manager, CLICK HERE whose actual role it is to answer practitioners questions. Why wasn't she replying to my Group Physiotherapy letters all those years? Why are (HF) using discipline rather than communication when managing Group Physiotherapy? Too much stick, more carrot needed.

 

Claim # 2: Differences within the Industry

  • The Australian Physiotherapy Association (APA) released a newsletter that was titled "A Chance to Fix Private Health Insurance". In this article, strong phrases were used. "Short-sighted actions by some private health funds", fixing private health insurance mess". The industry clearly needed sanitation and progress. What was I caught up in?

       CLICK HERE

 

There are isolated issues and also systemic ones in the industry. For what it is worth, the basic start to a solution to the health system is honesty, transparency, communication, and teamwork. A violation of these values, as (HF) did and the system breaks down, as you will discover through reading the information below. The less effort, the less insurance helps people, the more profit is made. 

 

  • Another Physiotherapy Association newsletter is below stating that (HF) unfairly treated a Physiotherapist for something he did not do wrong. Different case to me, but same health fund (HF). 

CLICK HERE

 

  • This is my understanding of the communication pathways for practitioners and health funds. Honest therapists, who want to do the right thing and confirm their understanding and or clarify interpretations, are at the mercy of the health fund responding, or not. In some cases, urgent answers are required for patients or services. Health funds that don't communicate effectively cause real issues. Issues to patient care, issues to efficiency and issues to businesses. In some cases vital and urgent questions are brushed aside and ignored. 

       CLICK HERE<< MUST READ

 

  • I wrote to the PHIO stating that when a health fund doesn't communicate, the system does not work. How do you gets answers, when they don't write back? Practitioners and patients are left stranded. 

  • CLICK HERE<< MUST READ

 

  • Below is yet another example of (HF) doing things differently than all other health funds. They should communicate openly and transparently when they go against the industry flow. They are the only ones that won't allow claims for Pilates. My business never offered Pilates. It is ok to be different and have your point of view. I am simply requesting honesty and communication from (HF) when they do. Also when a mistake is made, clean it up, not cover it up

CLICK HERE

 

  • My Health Advocate got involved with a meeting with (HF) to re-instate claiming at my facility. (HF) declined to look at my updated systems or notes. They showed little interest to collaborate.

CLICK HERE<< MUST READ

 

  • I sent many emails to (HF) questioning why there was such a large disparity between my business treatment and another, Business X. The reply answers were very limited, due to 'confidentiality'.  

 

  • (HF) stopped my Group Physiotherapy patient claims, so after a while of trying, I gave up the whole Group Service to my Exercise Physiology staff member. A huge decision. It seems (HF) had no interest to allow group claims at my service, no matter what we did or how hard we tried. They declined Group Exercise Physiology too. Why were (HF) so dismissive, stubborn toward us and lacked the patience and understanding that they displayed with Business X.

       CLICK HERE

 

  • As a student, I was inspired by the rehabilitation gym at Mt Wilga Hospital, one of Sydney's leading Private Hospital Rehabilitation Centers. The founder of that service has loosely mentored/encouraged me, over the years. Thank you, Nick. I was also inspired by the rehabilitation 'gym' within Royal Prince Alfred Hospital (RPAH) and the various acute and chronic conditions they helped. I visited the Strong clinic at Balmain Hospital to see how their gym equipment training program operated. My former partner overlooked rehabilitation work conditioning programs within gyms, for workers injuries that Physiotherapists supervised. A standard therapy. I met with people like Dr. John Grant, who helped to establish RNSH Department of Neurosurgery and Spinal Injuries Unit at RNSH and he was president of the 2000 Sydney Paralympic Games Organising Committee.

  • I Google clinical exercise 'gyms' and they are popping up everywhere run by Exercise Physiologists and Physiotherapists and they allow claims with health funds. It is obvious that 'gym' equipment and setup is a very powerful and widespread modality. Clinical exercise and rehabilitation are done within gyms within hospitals as standard therapy. Why was (HF) so against an innovator within the Group Physiotherapy community service industry, like me?

  • I was surrounded by a world of rehabilitation gyms, applying whatever I was observing and learning to my service, yet I felt like a fish out of water under (HF)'s judgment. I was so confused. It did not make sense. It was like (HF) believes the world is flat and I am showing and explaining it is round. Flat Earther's  have a weird conviction in their point of view. That was my experience.

no system.jpg

Claim # 3: Misappropriation or Manipulation

  • In order to understand where I believe manipulation occurred, one must understand the normal standards:

 

This is a basic Group Physiotherapy checklist I created and implemented, which the Australian Physiotherapy Association (APA) informally approved.

CLICK HERE<< MUST READ

 

We had been doing this for years. (HF) state they follow the APA guidelines, yet failed to re-audit me, even with my persistent requests stating I believed I had fulfilled what they wanted.

  • Below is a November 2013, APA newsletter stating that 'Classes' can not be claimed under 'Groups' with (HF). Yes, specifically written about (HF).

        CLICK HERE<< MUST READ 

  • A March 2014, email from the APA confirming that 'classes' are not to be claimed under 'Group' codes.

CLICK HERE

  • Yet another industry article stating that practitioners are unhappy with (HF) and to correctly code services. The message to the industry was pretty strong.

CLICK HERE

  • A more recent  email from a person in the role of Head of Business Integrity at another health fund. He clearly states that codes should not be switched under any circumstance.

CLICK HERE<< MUST READ 

 

       ***So now that we have a clear understanding that code swapping is taboo....

Why has (HF) been knowingly allowing misappropriation of patient treatment service codes for claiming, just for one Business X, for up to 10 years and continues to do so well after thorough industry warnings. In the patient claim evidence receipt example below, the service delivered was 'classes', the claim was given and made under 'Groups'​. 'Classes' have a maximum of $150 allocation per year. The receipt clearly shows more  than $150 claimed as the code should be P561 not P560. CLICK HERE<< MUST READ

  • Codes that do not match the service delivered is defined as professional misconduct.

  • Classes have a code of 561, they have a claiming limit of $150 per year at (HF). 

  • Groups have a code of 560, they have a claiming limit of $1200 per year at (HF). 

  • It is very easy to see the financial motive to switch code numbers by a practitioner or as a 'favour' by the health fund (HF). Everybody knows a 'class' is like a school 'class', everyone learning the same thing. It's obvious and clear. Why was (HF) the only company, who allowed switching codes for one business and being so coy about it?   

The following is an article for 'Service Descriptors' in 2012. Something (HF) withheld advising me about prior to my onsite audit. I saw it much later. On page 5, it clearly defines Classes and Groups. Something both (HF) and Business X chose not to follow. CLICK HERE. (page 5) << MUST READ

  • Groups are defined as:     

-  Pre-Intervention assessment

-  re-assessment every session     

6 people maximum                                                                                                                 

Different intervention concurrently                                                                                     

-  clinical record keeping                                                                                                                                                                                                                                                                                                          

  • Business X, released 'Group' claims receipts when they had up to 20 people in a class (there should be a maximum of 6. ​This person, my patient, whose name is withheld, provided a declaration of this fact.  

        CLICK HERE.<< MUST READ                                                                                                                                                                                                                                                                                          

  • Only three assessments were reported to have been done on this person in 8 years. An assessment is required at each session. People attending twice a week for years, should have hundreds of assessments. 

CLICK HERE<< MUST READ

                                                                                                        

  • Business X had up to 1,400 appointments a week, for up to 10 years. Advertised in a health fund (HF) publication. My patients who were attending there also or who knew people attending, reported to me most classes all did the same exercises, at the same time. When misappropriated claims are knowingly being done at such an epic level, most with (HF) insured patients, this amounts to millions of dollars. I say knowingly, as I asked 'Jody' about this and she said (HF) allowed it to happen.​ I also had a brief conversation with someone that works there.

CLICK HERE<< MUST READ

(It is interesting to note that (HF) took such a fond approach to Business X by advertising them, when, I believe this practice was not even accredited. We were in the process of accreditation. I don't believe Business X had students, we had students from 4 universities and happily teaching  our methods transparently. 

  • Meetings and arrangements had occurred with health fund (HF) and Business X staff. I was never given that liberty prior to my onsite audit and never had the opportunity for insights, a gentle modification or compromise. The difference of treatment between Business X and myself, was chalk and cheese. This directly led to my business demise. Why was I being targeted? 

CLICK HERE<< MUST READ

  • When I wrote to Business X to ask questions and seek clarification about services, I sent a registered, sign upon receiving, letter. I received no reply. 

        CLICK HERE      CLICK HERE

 

One of the points of advice the APA later gave me, was to connect with other practitioners. This strategy has obvious flaws, when the system is lacking transparency and favoritism. This occurred with one of Australia's highest private practice Physio claimers. Business X. They did not respond.

  • It is interesting to note, that Business X reported, that the health fund (HF) customer service desk staff advised their patients to encourage their Physiotherapists to swap codes for claims to 560, as they can receive larger rebates. (see below on 2nd page - red writing). 

CLICK HERE<< MUST READ

We have a real issue, health funds like (HF) fail to communicate, are aggressive with their audits,

have a swapping of claim codes culture and generally cause a lot of confusion This directly led to my business failing.

  • You would think some regulator is auditing these billion dollar companies, right. Wrong. It seems that health funds are not audited on their administration practices. This means anything could be going on behind closed doors and I firmly believe it is. This next piece of evidence is from the PHIO, stating no government organisation does audits.

CLICK HERE<< MUST READ

  • Health funds all interpret the regulations and apply them individually. (HF) did not communicate clearly to me at all and in fact withheld information when I asked about Group Physiotherapy. The next evidence clearly shows another health fund has its own interpretations of rules for Group Physiotherapy and communicated them to me. They allow maintenance claiming, (HF) does not. Health funds must communicate and share their interpretations.  CLICK HERE << MUST READ

 

How does (HF) justify being so aggressive with their on-site audit when they withheld information, allowed switching of codes and did not communicate, when they clearly do things differently to other funds. Very confusing and I feel unfair manipulative behaviour.

       

Claim # 4: False Facts

  • It was obvious to me, that my (HF) onsite audit had a predetermined outcome prior to starting. (HF) had no intention to understand my service, discuss. compromise or co-operate, like they did with Business X. It was obvious to me, that I was subjected to bad faith insurance practices treatment by (HF).

  • I can assure you the my business practice intentions were exceptionally clean, so why would (HF) be so dismissive and aggressive. Even IF, there was a significant issue found, why would a 'warning' not be given.

  • My audit is surrounded by very mysterious circumstances. Does this link explain what is going on:

  • External link:  http://www.jpands.org/vol21no4/ng.pdf  (please cut and paste in a new window)

​       

  • Below is a copy of the (HF) audit report. 

        CLICK HERE 

My comments to this  are below:

Patient records. As seen later in other patient hospital notes, patient entries are required in groups, this needed attention. This was addressed immediately. I accepted there was room for improvement for me.

Incorrect Itemisation. This is a false opinion. Our patients had a condition when they claimed, many referred by doctors and were doing individual programs, I believe inline with all the information I had been provided for by (HF) to date for Group Physiotherapy. I disagree with (HF).

Workplace Health and Safety. Adverse event procedures were never discussed in the audit. We had a very high safety record for 10 years, with numerous checks and measures in place. I disagree with (HF).

Treatment Plans. We did regular assessments, however, (HF) never advised of Group Physiotherapy to be assessed every treatment. We had plans, we had goals and re-assessed against these. We also had room for improvement which we implemented promptly. (HF) had our patient notes from 2 years ago and never raised any concerns, whatsoever. If things change, then (HF) should advise of changes. We were not given a fair go.

General Knowledge of patients. Recollection of details is challenging when you feel you have been set up by (HF) and you are being 'grilled' in a audit. Also, my memory is not my strongest trait.

The above points are very basic and easy to address. We definitely did not deserve such duress and a business driven toward failure. 

So not only did (HF) withhold regulations on 'Group' Physiotherapy to me, a service that is apples and oranges when comparing 'one on one' standard Physiotherapy, they isolated me and gave me a bad report card. Considering the circumstances, I do not feel it was warranted at all. Not a nice feeling. Standard auditing practices would allow a 'chance to make right', but we are learning (HF) do things a bit differently. (HF) escalated things without delay to the HCCC. I believe this to be a very aggressive and irresponsible action. The essence for my existence, my business, was being crucified. My business was my child and it was being unfairly bullied before my eyes.

      

  • Below is my formal reply to the Health Care Complaints Commission (HCCC) about the (HF) audit

       report. A lengthy and detailed document explaining each point from my audit.  

       CLICK HERE << MUST READ 

  • The HCCC accepted my reply and stated they had 'no issue'. I was relieved. I expected (HF) to get things back to normal with patient claims as I had also implemented (HF) additions to my service that they had requested. How wrong could be. Read on.

  • This is my response to blatant false information included in the (HF) audit report above. Yes, we did have many procedures in place for workplace health and safety.

        CLICK HERE

        and here is a copy of our incident report which existed at the time, that was never asked for

        CLICK HERE

I even have some forms filled out prior to the audit date, from minor incidents that occurred. Proof the audit lacked complete transparency and was not 100% legitimate and biased toward an outcome, not in my favour.

       

  • Also note in the second last attachment above, I was audited when we were going through our accreditation process by a Physiotherapy organisation (not compulsory and independent of (HF), So unfair. We were working hard toward our service being formally accredited and were aggressively judged by (HF). How could we possibly be crucified when attempting to do all the right things? 

It is important to note here my business had no issues whatsoever

with any other health fund, only (HF). 

                         ---------------------------

  • The former (HF) CEO stated to me that all correspondence (HF) had received from me was responded to. This is false. This is significantly false, as he is dismissing (HF)s lack of communication about the Group Physiotherapy rules to me. A violation to harmonious business relationships.  

  • 'Jody' from (HF), wrote that I started my service after the health fund (HF) started allowing claims for Physiotherapy Groups. This is false. I don't know the date when (HF) started Group Physiotherapy claims, possibly 2002, but I first registered my business name on the 10/11/1998, I suspect well before (HF) started Group claims. 

  • 'Jody', from (HF), wrote I was just a gym. What an insult. No other gym in Australia did the same thing as we did at all. Not even close. We built a Group Physiotherapy service (not a Class business) based on strong ethical principles, by starting ahead of the game and complete focus on the project of clinical exercise and rehab. It seems (HF) doesn't like innovation or having the spot light on their business practices. (HF) also had worked closely with Business X and had a 'class' model format that almost every gym in Australia uses as a vehicle of service delivery. I was advised at University not to do 'classes' as a service as it does not treat people's individual conditions. I believe 'classes' is a sausage making, cookie cutter business system. I seems ESSA agreed with me when I was invited to comment on Exercise Physiology service descriptor creation, as a stake holder (along with Medicare, DVA and health fund consultants). I objected to classes as being a good reflection on our industries principles. I believe they removed the term 'class' from the descriptors at the time. ​​​

  • As already stated, (HF) stated my service was just a gym. False. University student placements are not at gyms, so why would I have students from Sydney University, NSW University, Western Sydney University and UTS for years all learning the craft of clinical 'Group' exercise and rehabilitation. They were doing their Physiotherapy or Exercise Physiology degrees, some of them were masters students. (HF) showed little interest in understanding my service, (HF) never asked to see any of my detailed research folders, detailed assessment folders, detailed patient medical conditions program folder, detailed protocol/policy folders or detailed methods of service delivery. These were very comprehensive and robust as there future use, were to be used as the backbone literature for possible business franchising in the rehabilitation sector. My vision was to have medical centers attach my medical exercise service as an adjunct to their current service delivery model. Medical Centers are everywhere.

  • The word gym is just an adjective, hospital rehab centers are called gyms. My business was insured as a Physiotherapy, rehabilitation and clinical exercise business. Not a gym.

  • We placed large A-frame signs on the main road stating Physio, Gym and Rehab. Yes, we did advertise for fitness. Yes, we did advertise for Physio. Yes, we did we advertise for Rehabilitation. Yes, we did advertise for Clinical exercise programs. CLICK HERE

With the money I invested into my Physiotherapy business, if I wanted to own a personal training gym I could have bought 10 franchises. This was clearly not what I was about. 

As I can't reveal my previous actual business name, all I can say is that it had a strong bias toward medical exercise and rehabilitation. Clearly not a pop up, personal training name. These are some of the conditions and programs we created. CLICK HERE. We had numerous large folders, hard copy files, of Physiotherapy programs we had created for a plethora of conditions and post surgery protocols. There isn't much trivial about the 50s plus niche market we targeted. Dispersed with various musculoskeletal and medical conditions that could be helped with Physiotherapy exercises. It was a higher risk group to manage. It was a challenge, but it was worth it. 

Did we screen and provide receipts correctly for Group Physiotherapy (or later Exercise Physiology), to the best of my knowledge from any information (HF) provided, absolutely. Appropriate receipts, even when observing (HF) were allowing the switching of codes for Business X. Yes. We did do much more than Business X to fulfill on Group Physiotherapy, there is no debate, yet we get crucified and they get advertised with (HF).

I can honestly and am very proud to say, we never switched any codes (which happens), never provided a rebate incorrectly through another family member on the card, never swiped the health fund card or provided receipts for claims that were not delivered. I was a very proud Group Physiotherapist.

     

Back to the word 'Gym' which (HF) took a disliking to. Calling my facility just a gym, is like calling a hydrotherapy service a swimming pool facility, an optometrist business a sun glass shop, a dentist practice a teeth whitening clinic, a pharmacist shop a perfume dispenser. Yes, there are divergences, but the differences are obvious. What is important here, is the correct service delivery and correct receipts are given for Group Physiotherapy. Yes, we provided fitness programs too for 50's plus clients who had no medical history, but I was unaware of claiming receipts issued to them. In my eyes we provided Group Physiotherapy that was head and shoulders above, in complying to the rules, than Business X. Its obvious and clear as they were doing classes whilst claiming in a guise of groups. Groups is significantly much harder to provide and manage. 

When it comes to marketing, advertising key words are important. Buzz words and phrases like 'fitness' or our niche '50s plus', were used to attract people. Exercise with a medical reason. A certain high percentage had medical issues that could be helped with clinical exercise. Back and joint pain, arthritis, joint replacements, neurological conditions, osteoporosis, balance issues, age related muscle atrophy etc Statistically, a large percentage of 50s plus people have conditions that can be helped with clinical exercise programs, such as my Group Physiotherapy service.

 

Words like 'Group Physio', 'Exercise Physiology' had little meaning to the average person in the community and were not as widely used in general advertising. I used medical terms to medical people and basic understandable terms to the general community. Anybody with a grasp on marketing would understand that. 

When writing to doctors, it was clear I was a Physiotherapist providing group clinical exercise. 

Yes, a small business diversifies and offers a range of services, we did include fitness programs.

Does (HF) treat standard Physiotherapy practices that advertise for massage, with the same venom? Massage is not Physiotherapy. Is every Physiotherapy practice that advertises and offers massage, stopped for all its Physiotherapy claims. As a parallel example, that's exactly what (HF) did to me. (A side point, when I use to be a policy holder with (HF), I had regular massages for stress management various places, very rarely was there any initial assessment, most times notes were never taken, yet (HF) accepted claims at all these places. At some of these places , they didn't even speak English. So effectively we were creating a highly detailed, researched based Physiotherapy/ medical exercise facility, whilst at the same time (HF), permitted non-English speaking, no-note taking practices in healthcare. Standards were not equal or uniform. 

I don't want to get too off track, however (HF) offers various products too, including pet insurance. Anything for a buck. (HF) at the time clearly would have had less interest and put more business development into pet insurance than it did into communicating and developing rehabilitation services for people, like mine. Oh yes and (HF) do own a few 'gym' trademarks too.

  • Profits over patients over practitioners. This article clearly shows (HF) intentions to focus on profits from any source, rather than working with practitioners to build a robust health system for patients. (HF) has used some of its 2 billion dollar profits in the past, to invest in the Tobacco industry and fossil fuels. (HF) ethics as a health industry company, simply has to be questioned on this fact alone. 

        CLICK HERE​

Back to the story, backed with evidence,

  • In essence (HF) were saying I did personal training. What an insult. Comparing my Physiotherapy degree and years of ongoing training and experience, to a personal training course can be obtained in weeks.

  • This is just one example of the many courses advertised to Physiotherapists for 'gym' based therapy and rehabilitation. I went to many similar courses over the years. A standard therapeutic modality.

        CLICK HERE. You can see that ongoing education points are accepted, it is approved by our association. 

  • I clearly stated to the health minister initially, that I was not creating a regular gym, but a therapeutic exercise rehab facility. ie 'Group Physiotherapy' facility- I did not know that term at the time.

       That was always my professional goal.

       CLICK HERE<< MUST READ

  • There was no ‘gym’ that ran a Group Physiotherapy service like ours as my service was clinically based, Physiotherapy based, researched based using the American College of Sports Medicine research guidelines, built on university taught principles, everybody had an appointment, everybody had their own individually written program to follow, programs were continuously progressed and rewritten every three months. I didn't even use direct debit for over 10 years as almost every gym does. My service was driven by patient medical needs, not profit.  

​       CLICK HERE​ 

  • My facility, was in a suburb with very high rent. The rehabilitation area was 220m2, fully equipped with accessibility for wheelchairs, wheeler walkers, people with crutches and walking sticks etc. I was willing to pay the higher rent for ground floor wheelchair access. In my previous location, a stoke patient was brought in upstairs, assisted by four people. My Group Physiotherapy service also participated in a Sydney University research project for stroke patients treated in groups. CLICK HERE.<< MUST READ

  • (HF) propose they did two audits. This is absolutely false. At the second 'meeting' with my health advocate present, the (HF) representative and the consultant auditor refused to look at my updated systems and patient notes. I believe it was a 'token' meeting without any genuine attempt to work together. 

       CLICK HERE     

  • This next piece of information is not a false fact but one of the many errors (HF) made. (HF) systems had apparently allowed excessive rebates to a patient, breaching their own rebate limits.

        CLICK HERE 

 

Claim # 5: Intimidation and Bullying

  • (HF) were withholding Group Physiotherapy information from me for many years. Was this a mistake by (HF), probably, then (HF) tried to cover up its mistake.

       See same attachments above under Claim #1

       Was it malicious intent by (HF) and a deliberate suppression of my business with a motive?

       I hope not.

       Was it a reaction to (HF) being the first to offer claims for Physiotherapy Groups and that Pilates classes             were over claimed. Possible. (HF) are now the only health fund that doesn't allow Pilates classes claims.

   

  • (HF) were unfairly withholding Group Physiotherapy claiming for all my patients for an extremely extended period.​ Unfair. This was what my business was known for and mainly did, Physiotherapy in Groups.

  • A (HF) staff member arrived unannounced to my practice (even though he himself was friendly). I've been advised all health fund visits are to be notified in advance. 

  • Doing an onsite audit 40 days prior to releasing industry information on Group Physiotherapy is a very aggressive administration act. At the time of writing (HF) won't state why they withheld Group Physiotherapy information to me and then did an audit before releasing information. ['Jody', has since stated they were two independent (HF) actions. I don't believe it as it was too close together and Jody was manager of both sections. It would have taken much longer than 40 days to research, construct, approve and release (HF)'s letter]​

  • Two people against one practitioner is intimidating. I later researched that the Physiotherapist auditor is not a Physiotherapy Association member. This leads me to believe she is more interested in undermining therapists and the industry rather than supporting them, educating them. She is described as a terrier. CLICK HERE. The first question I would have asked, if I was her, would have been, have you heard of the service descriptors. My answer would have been, whats that? ( I had obtained the code number for patient claims at (HF) from a Business X receipt, that a patient had shown me. Information about Group Physiotherapy was gained from my patients about Business X. I was horrified to find out later on, it wasn't even Group Physiotherapy they were doing at Business X, but only putting receipts under that code for claims.) 

  • The onsite audit that was conducted on me was intimidating and lacked respect. It did not take into consideration (HF)'s lack of supplying me Group Physiotherapy rules, no feedback from previous patient notes and my offer to help (HF) write rules. (HF) was judging me on Group Physiotherapy when no Group Physiotherapy information was given to me by (HF) or my association. Crazy, but true.

  • Post onsite audit, there was no chance to ‘make right’ with (HF) escalating the situation to the HCCC and Physiotherapy council. This is simply wrong on all levels. I assure you at every stage I did my best to look after patients and complied to the best of my knowledge and ability on a professional level.

  • Removal of one-on-one claiming for my HICAPS (electronic claiming) machine. (which affected initial assessments for my patients and one-on-one Physio treatment claims.) This means they had to pay in full, then go to a store to make a claim. What a disruption. This is a significant inconvenience for my 50s plus patients, many with a functional limitation, to go into a (HF) store to claim with their receipts. They are not internet savvy to claim online. It is also very significant as (HF) said they wanted more detailed initial assessments and thorough assessments every 12 months. ​So why take this away from me. An aggressive action. Let me state this point again in another way, (HF) stated at the onsite audit they wanted more information/ different initial assessments than what we were doing, yet they cut off HICAPS claiming for the very thing they wanted. This is effectively, turning down/off the tap to my facility and forcing me into a vulnerable business situation.This greatly inconvenienced and upset my patients.

  • Customer service staff at (HF) advised my patients (who talk to the community) that I was non-compliant. This mixed message was very detrimental to my reputation. I went to exhaustive lengths to find information from (HF) and take actions on that information. All the while (HF) was allowing switching of codes to Business X. I consider my self very compliant and went to extreme lengths to do so. (HF) were spreading false rumors. Rumors are magnified when Group dynamics are the service being conducted.

  • The peak bodies, HCCC and Physiotherapy Council, requested a report from me after (HF)s onsite audit and did a thorough assessment. The peak body findings were ‘no issue’ on my service.

       

       HCCC letterCLICK HERE<< MUST READ

 

       Physiotherapy Council letterCLICK HERE<< MUST READ

       

       Yet the health fund (HF) ignored this and continued to withhold my patients’ claims.

  • Note, in the HCCC letter above, (HF) were advised of the finding that they: 'did not identify any evidence of concern' and invited (HF) for their right for a review. (HF) did not, take up this invitation, but instead persistently withheld my Group Physiotherapy patients claims for years.

  • Not only did (HF) stop Group Physiotherapy claiming at my facility, but when I transferred my limited number of (HF) patients to my Exercise Physiologist, they swiftly stopped claiming for Group Exercise Physiology too, just at my practice. It is important to note here that all other practices were allowed to claim Group Physio and Group Exercise Physiology except us. It didn't make sense, why were (HF) being so aggressive to us, when we were doing everything we could to please (HF), yet they were so lenient to other businesses like Business X, deviating from rules and swapping codes .

  • No re-audit, means no reinstatement of patient claims, means no rebates. 

  • As I had an Exercise Physiologist (EP) and having no joy regarding reinstating Group Physiotherapy, the facility was turned into an Exercise Physiology practice. This meant I owned a practice that 95% of the service I couldn't supply a service to. Over the course of 3 separate E.P. staff members, over 2 years, with specific focus to the task at hand, we couldn't get approval for Group Exercise Physiology either from (HF). I was very certain we were doing much more than 95% of Group E.P.s out there, yet our patients couldn't claim Group E.P. How could I be so certain, because I had seen over 100 students, by that time, who had spent time at various E.P. placements and had given me feedback. We were committed to our patients and we were so detailed in our work, following up on each and every indiscretion in order to improve. I was aware of and practiced a Japanese business philosophy called Kaizen, which means continuous improvement of working practices, personal efficiency, etc. Anthony Robbins puts it this way: C.A.N.I, Continual And Never Ending Improvement. This belief and my persistent pursuit of the truth, explains my motivation behind this website. Who knows where my business would be now, if I had used the energy to defend myself from (HF) attacks, toward business accreditation and development. 

  • No re-audit occurred, even after 4 years, even though I wrote to advise the health fund (HF) I believed I had fulfilled what they wanted. After years of delay, arrangements had came close for a re-audit after 4 years, but an injury which caused hospitalisation and my business sale prevented this from happening. It was all far too late.

  • I felt bullied out of my business and was fortunate to find a buyer who bought the business as a going concern due to my extreme stress before I had to close my doors. I wish him nothing but the best and am confident he will look after the patients/clients.

  • After exhaustive discussions and reviewing the health funds Group Physiotherapy information/policies and APA guidelines by 4 staff members, up to 15 students, Physio Association members, Physio colleagues, up to 10 legal people including a meticulous Barrister, the health fund still declined to accept my ‘test patient’ notes and allow a claim. This was my last strategy, it failed. I then went through with my business sale due to (HF) not being co-operative with me fulfilling Group Physiotherapy and reinstating claiming for my Group Physiotherapy patients.

  • Post business sale of my business, I demanded an appointment with 'Jody' at (HF). I managed to point out that the (HF) reasons for not claiming for my test patient which where; no initial assessment, no initials after each session and no goals, that in fact all had been done. It was obvious. Jody at (HF) had another look at my notes and finally accepted the ‘test’ patient claim, then rightly paid my patient the Group Physiotherapy rebate, as I had pointed out, these points had actually been done. It was so clear, but too late for me. 

 

Claim # 6: Authority angst

  • The health fund (HF) appeared, to me, to do everything it could to hide and cover up its ‘mistakes’ and incompetent treatment and behaviour towards me.

  • I had been doing Group Physiotherapy principles with honesty and to the best of my ability for 14 years and (HF) was doing everything to shut me out and shut me down.

  • This is an email to the Private Health Insurance Administration Council (PHIAC), they referred me to the PHIO.

       CLICK HERE​

  • Alan Jones also referred me to the PHIO. CLICK HERE

  • As I understand it, the Private Health Insurance Ombudsman (PHIO) is the policeman in the health insurance industry. These are a few of the many escalating emails I wrote seeking support and a resolution.

       CLICK HERE<< MUST READ

 

       Another message I sent to the PHIO, without success.

       CLICK HERE

     To my surprise the PHIO failed to:

      Penalise three separate incidents of code switching, that I reported:

      1) Patient claims being accepted by (HF) management when the service was 'Classes' under a 'Group' code, as described above. ($150 per year claims to $1,200 per year claims)

     

      2) Patient receipts being issued by Business X, for claims that do not match the service code.

     

      3) (HF) customer service desk staff encouraging the patient to advise practitioners to swap code numbers for patient claims. 

  • Even more of a surprise, the PHIO failed to read my 80 page Senate accepted report (report not on this website). This is the cover letter. CLICK HERE and the resolutions person at the PHIO office was instructed NOT to read the report and to send the report back to me. Perhaps they were just too busy.

     CLICK HERE<< MUST READ

      This is a letter to the PHIO seeking him to help and provide justice.

       CLICK HERE

  • Unfortunately the APA (Australian Physiotherapy Association) failed to advise of Group Physiotherapy rules when I asked. 

       CLICK HERE << MUST READ

 

  • The APA rightly so, apologised twice. I am grateful for that. 

        CLICK HERE​<< MUST READ

        [Find second apology from APA and attach] 

       

  • (HF) have never apologised and have done everything possible to cover up their mistake and shut me up and shut me out. Hence, I created this website, to raise my voice.

     

  • An early email to the APA clearly stating I needed help. CLICK HERE.

       I have been a financial member for about 25 years. 

       Ongoing frustration with the APA and seeking answers.

       CLICK HERE

  • The APA confirmed their views on how Health Funds should treat practitioners. Many of these things did not happen to me. 

       CLICK HERE<< MUST READ

       CLICK HERE

  • Mr Abbott was extremely helpful over the years and even tried to assist with my predicament with (HF). I had a meeting with him and his assistant. Unfortunately neither or both the PHIO and/or (HF) were willing to provide any information regarding a list of action points for me to do, to  re-instate Group Physiotherapy claiming for my patients. I had already written to them to advise I had addressed their onsite audit points. How could I possibly fulfill what they wanted if they continued to withhold information to my updated activities. Communication is a real key, that (HF) uses unfairly in its powerful position. A misuse of power.

       CLICK HERE

  • It is mysterious that Mr Abbott replied to every letter, every meeting request and an invitation to cut red ribbon at the begging of my business venture, but the only thing he did not respond to, was my request for an adviser to discuss my 80 page report about (HF), that I sent him. 

  • The NSW Small Business Commissioner's Office couldn't do much. (HF) originally agreed to attend a meeting then quickly changed their mind to offer me a 'Private' meeting, which proved unproductive.

        ​CLICK HERE<< MUST READ

  • I made a senate inquiry submission, my 80 page report. I didn't get any feedback as I don't think that was standard protocol.

        CLICK HERE​<< MUST READ

        My senate report summary is below and contains most of the information on this website page. 

        CLICK HERE​

 

       They had the information, but can't help me.

  • I spoke to the Commonwealth Ombudsman a few times. A great guy. He finally advised that if the PHIO office won't agree to a meeting and discuss the information, he didn't know what else to suggest. I know it is a crude analogy, but I feel like my business has been raped. So what does one do in these circumstances when you have concrete evidence for rape and the police don't want to discuss it and do nothing about it? ​Yes, just like what happened with young boys and priests. I did say a crude analogy, but is similar in its power play, control and authority doing nothing about it. Sick.

  • I wrote to Private Healthcare Australia (PHA) seeking some clarity about (HF) actions. The response back was that (HF) doesn't allow claims for Pilates classes. I am confused as we have never offered Pilates classes.  

       CLICK HERE<< MUST READ

  • I also queried the PHA about code swapping by (HF). Nothing was heard back at the time of creating this website. CLICK HERE

  • The Department of Health says there is nothing to stop a health fund allowing the swapping of patient service codes. They say its a 'commercial decision' . This is very concerning as the industry knows that misappropriated claims is called professional misconduct- fraud. I queried how does one tell the difference between honest swapping and malpractice. ​

       CLICK HERE<< MUST READ         

  • So it seems, communicating or not, switching codes, favoritism and discrimination are all labelled under 'commercial decisions'.

  • I waited until the very end to make a formal complaint against Business X to the HCCC. Surprisingly the HCCC didn't ask for any of my evidence, which I stated I wanted to discuss, before they made a determination. I then sent my evidence, a list of patients names to check patient notes and asked for a review. This was declined. They never requested any patient notes to review. Mysterious.

       CLICK HERE<< MUST READ

 

  • This is a copy of the Private Health Insurance Act 2007, which health funds are meant to follow.

        CLICK HERE

 

  • Here are some points that raised my concerns in the Private Health Insurance Act 2007 and the Competition and Consumer Act 2010. (my report is not on this website, but the information is)

       CLICK HERE​<< MUST READ

  • The appointed contact person, 'Jody', within the health fund (HF) refuses to advise me of her manager’s details. Surprisingly, head office administration also withholds her manager’s details. 

CLICKHERE<< MUST READ Is this a perfect example of 'Peters Principle'- people (Jody) being promoted up the company ladder to their 'level of incompetence'. If so, an incompetent person was behind my business demise and I can't even discuss it with her manager. It is also a point to mention that when my health advocate contacted (HF) early on, a (HF) colleague [possibly manager] answered the phone and got into a heated debate, as they didn't want to discuss my case. A formal complaint was made to (HF). 

 

  • As I needed answers, I also asked the PHIO- contact person who his manger’s details are and who he reports to. He did not respond.

  • The Department of Health contact person refuses to provide his/her name and discuss my situation over the phone.

 

  • I was lucky enough to find a Barrister (who he requested to be kept anonymous), one of the most articulate and considerate people I have met. He went through the health funds (HF) terms and conditions and the APA's service descriptors point by point as I had also done. We went through and confirmed that each point had been executed with my nominated 'test' patient, which reflected what we had been doing over the years with patients. He wrote a letter confirming I had fulfilled all requirements requested, to (HF) on my behalf, sent it to me, then I put my name on it and sent it to (HF). The health fund (HF) still declined the claim. This was absolute and the final proof to me, (HF) had targeted my business and ran me out of business. The Barrister said he didn't know what the magic password was. This confirmed the Small Business Commissioners Office appointed business adviser's sentiment that, "it seemed someone was trying to run you out of business". But who and why? The mystery continues. It is obvious that (HF) has every intention to defend its mistakes, do a full cover up and try to shut me up. The undeniable truth has been outlined above by outlining the major points and the full truth will come out in the end.  

  • It seems the practitioner has very little power and the health funds can almost do what they like, unregulated. Even when a practitioner like me raises concerns, little is done. Maybe the NSW state manager from another large health fund was right with his off the cuff remark- "If they don't like the colour of your carpet, they don't have to allow claiming for your patients." He too was a nice and helpful guy, he took many of my calls and came in for a chat about (HF). When I showed him my work, he said "very comprehensive". He also stated he disagreed with (HF) swapping code numbers. He had never heard of it and doesn't understand whats going on. 

  • It is a scary situation, as the larger health funds are now becoming service providers too. It seems there is nothing stopping them from switching codes, placing pressure on their immediate small business competition and slowly taking over a largely wholesome and harmonious army of practitioners, from various health disciplines. I believe the unregulated administration part of the health insurance industry is being abused, all under the guise of 'commercial decisions'. It is so obvious. 

  • This is a copy of a guide for 'Bad Faith Insurance' from a USA website. I used it as a 'rough' guide and picked out some points.

        CLICK HERE<< MUST READ 

 

From my experience these points have raised my concerns about 'bad faith' treatment:

- Denies payment without a reasonable basis

- Failure of insurer to acknowledge and reply promptly

- Failure to offer or attempt to effectuate prompt, fair and reasonable evaluation

- Policy which was altered without notice, knowledge or consent

- Failure of insurer to promptly settle claims (my situation)

- Using illegal and fraudulent investigative methods and procedures. 

- Using harassing, intrusive or demeaning investigative methods and procedures which victimise. 

- Failure of an insurer to settle a claim directly, when and where settlement is required, and instead requiring the insured to pursue a claim against another party first (HF often directing me towards the APA and the APA more lately refers me to (HF).

- Intentionally withhold, misinterpret or misconstrue claims information and/or failure to not inform insured of provisions and covered benefits under the policy pertinent to a claim.

- Attempts to use indiscriminate measures, reference and/or procedures that diminish or reduce

- Intentional or irresponsible non-disclosure and withholding of information, misinterpretation of file documents and/or policy provisions, that would be in favour (another practice) of the claimant.(non-compliant to (HF) or Physio rules)

- Wrongful threats not to pay claims. 

- Wrongfully deny or reduce payment of claims. 

- In conflict with industry standards.

- Failure to live up to, conform or comply to industry standards.

- Using inaccurate or wrongful information of a factual or legal nature to diminish, deny or delay payment of a claim. 

- Not being forthcoming with facts

- Using extreme undue persecution, wrongful and victimizing tactics and actions, meant to crush, threaten, thwart, intimidate, oppress

- Changing or altering policy coverage without informing

- Biased investigation of that which is supposed to be neutral and unbiased.

- Utilization of internal one-sided or outside companies biased schemes, such as in so-called "IME" bias , which are supposed to be objective and neutral , in order to wrongfully enable, facilitate and support insurer's position to fraudulently deny, reduce or discontinue payments of claims.

- Intentional miscommunication

- Same claims person of an insurer handling conflicting and both sides

- Deviating from standard procedures

- Abusing and/or misusing the system in order to delay

- Attempting to shift blame (saying the APA should have communicated with me, yet HF have a responsibility to explain their interpretation) and responsibility of investigation to insured and away from the insurer

- Intentionally misinterpreting or misconstruing (the physio rules)

- Deny treatment for a covered health benefit

- Unreasonable denial of a covered health benefit

- Unreasonable misinterpretation of policy language (allowing swapping of codes)

- Taking undue excessive advantage of unlimited time

- Health insurers not acting in the best interests of the patient and/or acting for their own self-enrichment at the health expense and disadvantage of the patient. 

- Some health insurer secretive deals are alleged to result in the health insurer selection

- Good faith insurers look for and find ways to accept and pay claims properly and promptly ... Bad faith insurers look for and find ways to not pay, delay, diminish, disapprove and deny payment of claims.

I feel (HF), from my experience, have many points resembling 'Bad Faith' insurance.

Claim # 7: Compensation Required

 

  • I believe I have been treated very unfairly, isolated, targeted and discriminated against by bad faith insurance practices. I have not been treated by normal industry practices at all. In the next evidence it shows a practitioners professional pathway. Rules are obtained from the health fund and the association. Prior to my onsite audit, both did not respond when I wrote to them, so I was judged on Group Physiotherapy where I had little, to no guidance. 

        CLICK HERE << MUST READ

  • I’ve invested up to 2 million dollars into my ’lost’ business and 14 years (20 years of my life’s work). I believe I am entitled to be compensated by (HF) for the unsavoury treatment towards me. The next 'click here' document is ACCC information about 'Unconscionable Conduct'.

        CLICK HERE << MUST READ

  • I went through hell addressing each and every new hurdle the health fund (HF) put up in front of me.

  • The health fund bullied me into dark spaces I dare not mention on this website.

  • Eventually I was running the whole business by myself (no staff) due to diminishing cash flow, which was an extremely stressful experience.

  • Yes, I did manage to sell my business, it wasn't by choice, but more like a survival act. Reputation is probably the most valuable thing in a service business and (HF) had manged to destroy that after 14 years of hard work. No Physiotherapist or Exercise Physiologist was interested in buying my business after hearing my reasons for selling was due to (HF) issues. I was only left with interested parties who were personal trainers. Admittedly not my preferred target group to carry on the legacy. I was lucky to find a good guy to buy it. 

  • The impact of my experience was so significant that I have not worked as a Physiotherapist in any clinical capacity since, except in administration to understand Group Physiotherapy. I am scared that I have no rights and nobody can advise me what I could have done differently when relating to (HF). I am petrified, that if I started all over again, what is to stop the same thing happening. ie a health insurance not communicating, making mistakes, being incompetent and projecting it back onto me and forcing me out of a business. Lets face it, insurance doesn't care about people, yet they have managed to take over the system. 

  • There is no authority or entity that can confirm a service to be ‘Group Physiotherapy’. The HCCC state their findings of 'no issue' on my business are their own and health funds can ignore them if they like. The only way, I know of, to get Group Physiotherapy approval is through accreditation. This is exactly what we were doing. It just so happened that my practice was half way through accreditation. It seems that the health fund (HF) withheld all information on Group Physiotherapy to me for 8 years - we were going through the processes of accreditation and (HF) judged us prior to completion, I must say in a very aggressive manner. Remember (HF) were grossly allowing the switching of codes for patient claims, defined as professional misconduct, to the tune of millions of dollars. What confusion and mess (HF) created, then they project it back onto me. Grossly unfair, un-Australian.

  • Due to the ongoing suppression by (HF) and no re-audit or reinstatement of Group Physiotherapy claiming in sight. Due to the extreme stress and concern at the back of my mind that another health fund could treat me in the same way, petrified in fact, I advised all my patients they couldn't claim with their fund until I resolved Group Physiotherapy with (HF). CLICK HERE As a professional and on a personal level, I needed absolute certainty what Group Physiotherapy was. I was confused even though I had many people pouring over what (HF) wanted and I was taking actions on every (HF) point. The whole situation was so in congruent.

 

  • In the end I had written hundreds of emails, spoken to up to 40-50 intelligent people including staff, colleagues, students, patients, other health funds, legal advisers, authoritative bodies, associations, other health funds, even a Barrister, but (HF) were so stubborn, for no reason, in their approach. They didn't care about my patients or my practice. I was forced to sell.  

  • There was a small part of me and a voice in my head, that wanted approval for doing Group Physiotherapy (and Exercise Physiology) as we had been for years, so I persisted (even after I sold my business) with a nominated 'test' patient to get a rebate, even when earlier he had been refused his claim by (HF). [It was too late for business accreditation now, as I had sold my business] Previously, I had gone through point by point on (HF)'s terms and conditions CLICK HERE - (Document un-linked as I didn't know how to hide (HF)'s name on original pdf document. It is available upon request) and over the Group Physiotherapy service descriptors with a Barrister. Conclusion, I fulfilled the points for this 'test' patient and believed I had been for my Group Physiotherapy patients for years. The Barrister wrote a letter, stating the points were fulfilled and I placed my name on it. Unbelievably, (HF) still declined. The Barrister said he didn't know the magic code was. 

  • I let it go for a short while, then finally I asked to meet with Jody at (HF) to discuss why the 'test' patient was declined. In the meeting she said because no initial assessment was performed and there were no initials after each session. I was mortified. Once again as with most steps of the journey, (HF)/Jody were incompetent and factually wrong. I quickly pointed out what she had overlooked. Yes, those points had clearly been done, it was obvious. These points had been done for years with our patients as I had previously written. 'Jody' may have been analysing assessments being done on the patients at my practice via statistics, rather than asking me, but this would not register because I made a customer loyalty decision to give complimentary initial, Group Physiotherapy assessments. The fact is that they were done. Yes, I wore the heat from (HF) and did not pass it onto the current patients. This also meant the disruption tactic (HF) intentionally caused by switching off HICAPS claiming at my facility for these assessments, was neutralised. Under my watch, I wanted minimal disruption, my patients were protected and respected as much as I possibly could, whilst my world was caving in. It was the least I could do to show my appreciation to my patients. Without them, I had no purpose.

  • It was mixed emotions when shortly after, my 'test' patient was rebated for Group Physiotherapy by (HF).

       CLICK ​HERE<< MUST READ

  • The issue now is, I believe we had been fulfilling requirements for years without (HF) agreeing to look at the notes or the updated systems.

Now I have no business.

Thank you for your time and attention whilst reading my story.

Current Situation:

- I am awaiting copies of (HF) multiple letter responses to my letters prior to my audit. The basis for this whole case and demise of my business all falls upon these letters that I have never seen, as they don't exist.

- I am still awaiting a reply from the (HF) CEO, the PHIO and my association regarding these letters.

- The HCCC did not request patient notes from business X for reviewing from the practitioner in question as I indicated and did nothing about codes being switched for patient claim receipts that did not match the service.

- I reported 4 separate cases of code switching for patient claims to the PHIO, I do not know of any escalation or disciplinary action taken by this authoritative body.   

Unanswered Correspondence:

I gave the HF CEO a chance to explain a few basic points. My main email address was blocked and when I used my backup email, there was no reply. CLICK ​HERE<< MUST READ

What would you do if you were me? 

Do you believe I have been treated inappropriately? Abuse of position and power perhaps? 

How much do you believe (HF) should compensate me?

 

This is my story, if you have had issues within the private health insurance industry, I’d like to hear about it.

 

Contact me, Monte, via SMS on 0410675545.​

 

The purpose of this website to:

  1. Support anyone who has been denied a legitimate health insurance claim.

  2. Support any practitioner struggling with bullying tactics by health insurance.

  3. Seek compensation from the health insurance company (HF) for being unreasonable.

       (this I feel, can only be achieved by extra social media support)

   4. Media exposure, so no patient or practitioner or business ever gets bullied to the degree I did, ever again.

Group Physiotherapy

Group Physiotherapy

Sydney, Australia

Email: Upon request.

Mob: 0410 675 545

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Founder and former owner of a multi award winning service, is forced out of business due to bad faith health insurance.

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© 2018 by Monte Elissa. 

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