Private Health Insurance Claims Leakage and Fraud Forum 2015


Click here to download the PHA Fraud Forum 2015 Program. (1.17 MB)

Speakers, Biographies & Presentations

Hon Dr Michael Armitage, Chief Executive Officer, Private Healthcare Australia

Hon Dr Michael Armitage
Dr Armitage is the Chief Executive Officer of Private Healthcare Australia (formerly AHIA), the peak body representing health funds in Australia.

Dr Armitage was a Member of the South Australian Parliament from 1989 to 2002, and a Minister from 1993 – 2002. In particular, he held the Health portfolio from 1993 to 1997.

Before entering Parliament, Dr Armitage was in private practice after serving as Paediatric Registrar in Adelaide Children’s Hospital and as a House Surgeon for Invercargill New Zealand.

Since leaving Parliament, he was involved in the Super Computer industry, as the Director – Sciences (ANZ) for Silicon Graphics (SGI) before joining Private Healthcare Australia as CEO in November 2005.


Special Agent Michael Badolado, FBI Special Agent, Federal Bureau of Investigation

Download Presentation – Identity Theft and Healthcare  (5.24 MB)

Michael Badolado
Michael has worked with the FBI in Baltimore, Maryland; Atlanta, Georgia; and St. Louis, Missouri, USA as a Special Agent. For the past 11 years his efforts with the FBI have focussed on health care fraud investigations.

Previously he worked with Express Scripts, Inc. in St. Louis where he was a Clinical Programs / Account Manager and St. Luke’s Hospital also in St. Louis as a Medical Coder / Utilization Review.

Michael has a Master of Business Administration (MBA) from Lindenwood University, as well as a Master of Health Care Administration (MHA) from St. Louis University and a Bachelor of Science (BS), Health Information Management also from St. Louis University.


Mike Byrne, Risk, Compliance and Fraud Manager at Southern Cross Health Society

Download Presentation – Organised Crime in New Zealand  (2.43 MB)

Mike Byrne
Mike currently leads the Risk, Compliance, Fraud and Provider Audit teams for New Zealand’s leading health insurance business with more than 800,000 members.

Prior to joining Southern Cross in June 2014, Mike’s background was in the NZ Financial Services sector leading operational risk, fraud, security, continuity, crisis & insurance capabilities for large NZ corporates. His past roles included leading Risk, Fraud and Security operations for ASB and BNZ banks, and Operational Risk / Business Continuity for GE Capital’s New Zealand businesses. He also has experience in Continuous Improvement and Quality Management, having previously assessed with the NZ Business Excellence Foundation’s National Quality Awards.

Mike brings us a business perspective on organised crime in New Zealand, its touch points into NZ businesses, and some of the key strategies being used to combat illegal and deceptive activities.


Professor Des Gorman, Executive Chair Health Workforce New Zealand

Download Presentation – The Challenge of Clinician and Health System Leadership  (503 KB)

Professor Des Gorman
Professor Des Gorman is Executive Chair, Health Workforce New Zealand and Professor of Medicine and Associate Dean, Faculty of Medical and Health Sciences, at the University of Auckland.

He holds a BSc, MBChB and MD from the University of Auckland, as well as a PhD from the University of Sydney. The two doctorates were awarded for in vivo research into brain injuries.

Professor Gorman’s primary research and clinical interests are brain injury, diving medicine, occupational medicine and toxicology. His research career includes more than 250 publications.

He is a Member of the Board of Directors of the New Zealand Accident Compensation and Rehabilitation Corporation (ACC), as well as a Member of the National Health Board and the Capital Investment Committee, Ministry of Health.

Professor Gorman is currently overseeing health reforms in a number of different jurisdictions.

He has served in both the Royal Australian Navy and the Royal New Zealand Navy. During his service in the former, he trained as both a submariner and as a diving officer.


Craig Gregory, Group Loss Prevention Manager, HBF Health Ltd

Download Presentation – Case File Lodgement  (1.84 MB)

Craig GregoryCraig is the Group Loss Prevention Manager for the HBF Group of companies. In this role, Craig is responsible for hospital / medical audits & investigations, ancillary investigations, compensation recovery, internal fraud controls & investigations across HBF and GMF Health Funds.

Prior to this role, Craig was a Senior Manager with Ernst & Young’s Fraud Investigation & Dispute Services team where he led a team in fraud and corruption related investigations, anti-fraud activities and risk management. Craig was formerly the National Enforcement Coordinator of a Commonwealth Government agency where he was responsible for developing the organisation’s investigative and enforcement capabilities and led investigations into national security matters.

In 2006 Craig was in charge of the Dili Criminal Investigations Office for the United Nations’ Mission in Timor Leste, and preceding this was a Detective for 9 years with the Western Australian Police.


Detective Superintendent Brian Hay, Queensland Police Service

Download Presentation – Growing problems in eMedical Crime  (11 MB)

Detective Superintendent Brian HayDetective Superintendent Brian Hay has been a member of the Queensland Police Service for 34 years. Since 2004, Mr. Hay has had principal responsibility for the management and direction of the Fraud & Cyber Crime Group, State Crime Command.

Mr. Hay has a broad investigative background with forays into the investigation of drugs, outlaw motorcycle gangs, sexual predators and public sector corruption. These duties have been interspersed with uniform general duties and corporate responsibilities.

He is often sought for media comment within the fraud and cyber environments. Mr Hay was a pivotal driver in a number of key national initiatives and has a proven record in partnering industry.

He has led Australia’s effort in respect of combating Advance Fee Fraud and its proliferation via the cyber environment.

He was the inaugural Chair of the ANZPAA (Australia New Zealand Police Advisory Agency) eCrime Working Group and a member of the National Cybercrime Working Group.

He is a member of the International Mass Marketing Fraud Working Group.

In 2006 Mr. Hay completed a Masters in Public Policy and Administration.

In 2009 he was the recipient of the Australian Police Medal.

In 2009 he was the recipient of an international award from McAfee for efforts in combating cyber crime.

In 2010 he was the recipient of the National AusCERT Award for Individual Excellence in Information Security.


Marty Latimer, Head of Protective Services, Suncorp Group

Download Presentation – Flipping the fraud problem – know your customer  (786 KB)

Marty LatimerMarty Latimer is the Head of Protective Services at Suncorp. He leads the Financial Crime, Physical Security, Cyber Security and Resilience teams to ensure the group is protected against threats and disruption.

With 20 years experience in Fraud and Security management and 5 years in CRM analytics, Marty is able to apply a commercial lens to solve crime related challenges.




Ian Laughlin, Deputy Chairman, Australian Prudential Regulation Authority (APRA)

Download Presentation – Introduction to APRA as the new regulator of Private Health Insurers from 1 July 2015  (212 KB)

Ian LaughlinMr Laughlin was appointed as a Member of APRA on 1 July 2010 for a three-year term, and was reappointed Member and appointed Deputy Chairman for a two-year term commencing 1 July 2013.

Mr Laughlin is APRA’s representative on the Executive Committee of the International Association of Insurance Supervisors and on the Financial Reporting Council. Mr Laughlin has extensive experience in the financial services industry. He has been a non-executive director of AMP Life Limited, serving as Chairman of its Board Audit Committee, Managing Director of the United Kingdom life insurance subsidiaries of AMP (Pearl, London Life and NPI), director of HHG plc and non-executive director of Diligenta Ltd in the United Kingdom. Before then, he held senior management positions in AMP, Suncorp and National Mutual in Australia, New Zealand and Hong Kong. Mr Laughlin has also served on the Council of the Institute of Actuaries of Australia.


Deniza Mazevska, Associate Director, Health Policy Analysis

Download Presentation – Cost impact of hospital acquired diagnoses  (1.02 MB)

Deniza Mazevska

Deniza has had 20 years of experience working in the health system in a range of roles. Over this time, she has had exposure to a broad range of health areas, and has worked in strategic as well as operational positions. Her expertise is in health policy and strategy development and implementation, funding, performance evaluation, review and redesign of business processes, development and appraisal of models of care, and design of tools and approaches to collect qualitative and quantitative data.

Deniza joined Health Policy Analysis in 2008, after successfully consulting independently. Prior to consulting work, Deniza worked in senior positions within what is now the NSW Ministry of Health. Her last role in the Ministry was in 2005, as Director, Performance, Analysis and Reporting Branch.

Deniza has experience in a wide range of clinical areas, having worked on projects in a variety of specialties. She has developed and reviewed clinical care standards and models of care in areas such as cardiology, neurology, oncology, orthopaedics, mental health and palliative care.

Deniza has also worked internationally. For example, recently she worked with the National Health Insurance Company in Qatar to develop pricing for a wide range of services covered under national health insurance scheme – Seha. In particular, she developed the payment rules accompanying the price schedule, and designed and delivered training to health service providers on these rules.

Deniza is also an expert in clinical coding and classification development. She has formal qualifications in health information management, and worked as a clinical coder in hospitals in Australia. She has also developed classification systems. For example, she has worked on the Australian Refined Diagnosis Related Groups (AR-DRG) classification over time, she has reviewed classification systems for non-admitted care and emergency care, and she has developed classification systems for medical and surgical disciplines and hospitals (i.e. grouping them into ‘peers’ based on similar parameters).

Deniza was also a lecturer for the University of Sydney, where she taught undergraduate and postgraduate students in Australia and overseas in financial/resource management, funding and information systems.


Matthew Michael, Head of Fraud, Veda Australia

Download Presentation – Health Insurance Fraud Focus Group – Health Community Working Together To Manage Fraud  (2.73 MB)

Matthew Michael

Matthew has over 15 years of experience in the fraud and financial sector working in various areas of fraud and risk including management of strategy and operational risk, analytics, operations, investigations, special projects and the product development lifecycle.

As the Head of Fraud for Veda Australia, Matthew owns the development and enhancement of new and existing fraud solutions and is also responsible for the growth of the fraud business.

Matthew successfully provides fraud consulting and product solutions for fraud, cybercrime and AML to the largest financial institutions in Australia and has established a trusting network with industry participants.

At Cuscal Matthew established a new fraud management service named ‘Vigil – Fraud Bureau’ to provide credit and debit card fraud management services to over 40 Credit Unions.


Diana Newcombe, National Director, Legal Services

Download Presentation – Regulating Health Practitioners – Managing risk to the public  (2.29 MB)

Diana NewcombeDiana has 17 years of diverse legal and management experience in Australia and the UK. Prior to her role as National Director, Legal Services for AHPRA, she was AHPRA’s South Australian State Manager for three years.

Her legal work has included 5 years as a senior legal counsel with one of the UK’s largest private hospital providers, General Healthcare Group. In private legal practice in the UK, she was at the forefront of the development of international regulatory compliance programs and developed an award winning legal management model – for which she was recognised by the American Lawyer Magazine in July 2013 as one of the top 50 law firm innovators of the last 50 years.


Associate Professor Jim Pearse, Director, Health Policy Analysis

Download Presentation – Cost impact of hospital acquired diagnoses  (1.02 MB)

Jim PearseOver the last twenty years Jim has been active participant and leader in health policy issues and research both within and outside of government. Outside his principal areas of work, Jim has maintained a keen interest and involvement is social policy issues and over the last 10 years was the Deputy Board Chair for one of the leading non-government agencies working in child and family welfare (Barnardos Australia).

Since 2003 Jim has lead the consulting company Health Policy Analysis, which has been successful in a market which includes all the large management consulting companies. Health Policy Analysis has completed around 80 health sector consulting projects for Commonwealth government, state government and non-government clients. Projects undertaken have included program reviews, development of performance frameworks and measures, economic analysis, the development of business cases, and the analysis and interpretation of performance indicators. Health Policy Analysis has developed a wide network of expertise which it has often called on in developing competitive proposals and high quality results.

Jim is an Adjunct Associate at the Center for Primary Care and Outcomes Research at Stanford University, where he has collaborated with international researchers from 20 countries on the Global HealthCare Productivity Project (GHP). In 2005 he assisted with the development of the program for the China Health Policy Roundtable, held in Beijing and jointly sponsored by the China Ministry of Health and the George Institute. Jim is currently a member of OECD Health Care Quality Indicator Expert Group (Responsiveness/Patient Experiences), which provides expert advice to the OECD Responsiveness/Patient Experiences Subgroup, on the development of internationally comparable measures of patient experience of health systems.

Professionally, Jim is a trained health economist (Master of Science, Health Economics) at the University of York in England, and also holds Bachelor level degrees in Economics (Queensland University), Arts (Sydney University) and Social Work (Sydney University). He is also a registered SAS Consultant.


Phil Ross, Investigations Provider Networks and Integrated Care, Medibank Private

Download Presentation – Case File Lodgement  (1.84 MB)

Phil Ross18 years in Victoria Police and 20 years overall in policing.

Medibank – Investigations Provider Network and Integrated Care: August 2014 – present

* Detection and investigation of all fraud related matters
* Police liaison – Brief preparation – court liaison
* Data mining and member / provider profiling

Private Investigator: November 2012 – August 2014

  • Investigate general insurance claims, corporate theft and fraud
  • Prepare factual reports and provide recommendations
  • Analyse and comment on Forensic Reports

    Victoria Police: March 1994 – November 2012

  • 3 years at Sergeant level and two years at Acting Detective Sergeant level mentoring and managing junior members
  • 7 years Detective experience investigating all facets of major crime including high end thefts, armed robberies, sexual assaults and drug offences
  • Investigation of protracted and complex fraud matters


    Barry Sandison, Deputy Secretary, Health, Compliance and Information

    Download Presentation – Contributing to the Integrity of the System – Medicare Compliance  (3.55 MB)

    Barry Sandison
    As Deputy Secretary of Health, Compliance and Information, Barry Sandison is responsible for providing leadership and management of health related programmes administered on behalf of the Department of Health and other agencies. The Deputy Secretary is also responsible for managing the department’s health compliance programmes, welfare appeals and debt programmes and strategic information management activities of the department. Mr Sandison also performs the role of Chief Executive Medicare.

    Previously, Deputy Secretary of Participation, Families and Older Australians was responsible for welfare-related program activity and policy. Barry’s group worked closely with partner agencies such as the Department of Families, Housing, Community Services and Indigenous Affairs (FaHCSIA) , the Department of Education, Employment, and Workplace Relations (DEEWR), the Department of Industry, Innovation, Climate Change, Science Research and Tertiary Education (DIICSRTE) and the Department of Immigration and Citizenship (DIAC) on current and future approaches of the delivery of welfare, income support and child support services to every Australian.

    Barry over 30 years of public service experience across a number of departments and prior to joining the Department of Humans Services held key Senior Executive positions in FaHCSIA and DEEWR.

    In FaHCSIA, Barry was the Deputy Secretary responsible for Families, Communities and the Office for Women. Earlier he was also responsible for families’ policy and program functions, including Family Tax Benefit, Baby Bonus, Paid Parental Leave, Child Support policy and the Family Relationship Services Program.

    Barry’s responsibilities in DEEWR included Working Age Policy, employment policy and steering the policy aspects of employment reforms.

    Barry also worked in areas involving policy and reform of Disability Employment Services in the then Department of Family and Community Services where he managed the implementation of participation reforms.

    Barry has a Bachelor of Arts in Business Management and an Associate Diploma in Business Management.


    Gary Setter, Quark and Associated Pty Ltd

    Download Presentation – Identity Fraud  (3.45 MB)

    Gary Setter
    Gary has an extensive background in investigations, with 26 years’ experience in criminal investigative environments within various Commonwealth and State bodies, which has included service in the military within the Naval Investigative Service, as well as senior level investigative positions within the Australian Tax Office, the Health Insurance Commission (now known as Medicare Australia) and the South Australian Department for Education and Child Development.


    Neil Smith, Investigative Researcher & Trainer, Open Source Intelligence Techniques

    Neil SmithAfter serving over 10 years as a police officer in a major UK police force and time spent working as a counter-fraud specialist for a government department and as a fraud investigator for insurance companies, Neil has spent most of the last 12 years as a full time investigative researcher for a mixture of clients, from insurance companies to law enforcement agencies and journalists.

    Also during this time Neil has taught many hundreds of investigators, mostly from law enforcement but also private & corporate investigators in the art of using the Internet as an Investigative Tool. These courses and presentations have taken him all around the world.


    Jacob Suidgeest, Director, Regulation and Strategy, Office of the Australian Information Commissioner (OAIC)

    Download Presentation – Getting privacy right  (383 KB)

    Jacob SuidgeestJacob Suidgeest is the Director of Regulation and Strategy (Health and Privacy Assessments) at the Office of the Australian Information Commissioner (OAIC).

    Jacob is responsible for the OAIC’s regulatory and strategic policy response to privacy issues across a number of areas, particularly in Health, eHealth and information security.

    Jacob’s section conducts all the OAIC’s assessments (formerly known as audits) of organisations and agencies against the Privacy Act and related Acts.

    Examples of Jacob’s other work includes producing guidance for consumers and entities about privacy and health; advising the Department of Health on Privacy Impact Assessments on changes to the eHealth system; and updating the Guide to Securing Personal Information which is a resource to help agencies and organisations to meet their obligations under the Privacy Act to take reasonable steps to protect personal information.