We’re seeing a noticeable increase in restitution requests from private health insurers, particularly relating to take home bleaching kits (119) and application of desensitising agents (165). In most cases, these issues come down to simple “auto-pilot” claiming habits at the front desk rather than deliberate misuse.

A key area of confusion is Item 119 (take-home bleaching). Since July 2022, the Australian Schedule of Dental Services and Glossary (13th Edition) has specified that this item number can only be claimed once for the entire course of treatment, and no longer per arch.

It’s important to note that HICAPS is likely to approve the claims at the time of processing, even if they’re not consistent with the current Schedule. Unfortunately, these discrepancies are often picked up later during health fund audits, which can lead to requests for repayment.

Advisory Services is also continuing to see issues with the use of Item 165 (desensitising). While the descriptor hasn’t changed, it’s often misunderstood. Item 165 is claimable per appointment and not per tooth, and errors commonly occur when treatment for multiple teeth are incorrectly claimed during a single visit.

A quick refresher and a few simple checks can go a long way in avoiding these situations:

• Keep the current Schedule and Glossary handy and refer to it regularly
• Make sure your team understands commonly used item numbers
• Take a moment to review claims before submission.

A small investment of time upfront can help prevent the inconvenience of audits and the need for restitution down the track.