The Canadian Story The Canadian Health Care Anti-fraud Association

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The Canadian StoryThe Canadian Health
CareAnti-fraud Association

• Joel Alleyne, Executive Director
• Canadian Institute of Actuaries
• Annual Meeting
• Ottawa, ON
• June 30, 2006

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The Health System in Canada

• Approximately 130 Billion system
• Funded both publicly (70) and privately (30)
• Canada Health Act
• Provincial health care plans

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The Health System in Canada

• Private insurers
• Three largest account for over 60 of the
  business
• Active mix of
• for-profit,
• not-for-profit, and,
• third party administrators
• /benefit managers

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The Health System in Canada

• The debate continues
• Federal involvement
• Private health care
• Waiting lists
• Staffing shortages

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Canadian Health Care Anti-Fraud Association

• Founded (formally) in 2000
• Strategic Partnership of Canadian
• private and public health care
• insurance payers, and Law enforcement
• Membership open to regulators and
• provider associations

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Canadian Health Care Anti-Fraud Association

• Vision
• To improve the Canadian health care environment
  by eliminating health care fraud.

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Canadian Health Care Anti-Fraud Association

• Mission
• Our mission is to combat health care fraud and
  assist in restoring the integrity of the Canadian
  health care system.

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Problems and Opportunities

• On several fronts
• Providers
• Plan sponsors
• General public / claimants
• Awareness of the problem
• Importance of the problem
• Senior level commitment and support

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Accomplishments

• Raising Awareness
• Conferences / Regional seminars
• Sub - committees
• Advocacy
• e.g. Privacy, Legislative amendment e.g.
  Regulated Health Professions Act
• Communication
• web-site, media, sharing information/expertise
• Liaisons e.g.
• Law Enforcement, Regulators, Provider
• EHFCN
• Associations, US based carriers, NHCAA, FBI,
• NW4C

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What is Health Care Fraud?

• Our working definition
• An intentional deception or
  misrepresentation that the individual or entity
  makes knowing that the misrepresentation could
  result in some unauthorized benefit to the
  individual, or the entity or to some other
  party.
• (NHCAA Guidelines to Health Care Fraud)

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• Health care fraud remains uncontrolled, and
  mostly invisible. this problem represents one
  of the most massive and persistent fiscal control
  failures in their history.
• For those who profit from it, health care fraud
  is not seen as a problem,but as an enormously
  lucrative enterprise, worth defending
  vigorously.
• Malcolm K. Sparrow
• Professor, Harvard University - Kennedy School of
  Government
• License to Steal, How Fraud Bleeds Americas
  Health Care System

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Health Care Fraud Schemes

• 1. Billing for services/supplies not
  performed/provided
• 2. Intentionally making misrepresentations to
  obtain payment for services/supplies
• 3. The deliberate performance of medically
  unnecessary services for the purpose of financial
  gain

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Who Commits Health Care Fraud?

• 1. PROVIDERS
• 2. SUPPLIERS
• 3. PATIENTS
• 4. PLAN SPONSORS
• - may act alone or with other participants
• - may involve complex schemes or
  conspiracies, including
  organized crime

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The Appeal of Health Care Fraud

• Diversity -many private and public payers - lots
  of
• Multiple victimization common
• Assumption of honesty - good faith system
• System geared to pay claims rapidly, efficiently
• Safe, push of the button crime
• Victimless crime
• Detection unlikely

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Victims and Impacts

• Financial Victims - e.g. Insurers, Employers,
  Public at Large
• Higher taxes / premiums / prices
• Less money available for the deserving
• Reduced coverage/ insured services
• Potential of Physical Harm
• False medical/billing records may affect future
  employability and/or insurability

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Fighting Health Care Fraud contd

• Detection
• Provider profiling using data mining tools
• Identify high risk behavior using fraud red
  flags and benchmarks in data
• On-site provider audits
• Pre-payment/post payment audits
• Audit / verification / EOB letters
• Tips line
• Monitor known problem providers closely

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Fighting Health Care Fraud

• Prevention
• Monitor trends, keep current
• Educate/train staff, ins. plan sponsors, patients
• Employ skilled Practitioner Consultants
• expertise best practice information
• Advise providers of fraud and abuse policy, and
  business expectations
• Strategic partnering / networking

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Fighting Health Care Fraud contd

• Investigation
• Special Investigation Units
• Referral to Police Services
• Complaints to Regulatory Bodies
• Decline fraudulent claims
• Recover unauthorized payments
• Restitution orders / Victim Impact Statements /
  Crown assistance
• Recommendations for process controls

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Working With Law Enforcement?

• Effective communication
• e.g. Advisory notices Health Care Fraud
• Alert
• Assistance in Health Care Fraud training
• e.g. conference / seminars
• Analytical support
• Utilization of Experts
• Medical necessity review
• IMR opinions
• General coordination between Law
• Enforcement the Insurance Industry
• Joint Investigations

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Some Case Studies

• CBC TV Investigative report - dental
• A woman from Brampton charged with 234 counts of
  double doctoring and fraud for prescription
  narcotics
• A pharmacist charged with obtaining prescriptions
  for high priced drugs and paying the patient a
  percentage of the total prescription not
  dispensing the meds however billing ODB for the
  prescription.
• A US citizen charged who was receiving insured
  medical services for which he was not entitled

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Some Case Studies

• Foot care practitioners charged with submitting
  fraudulent claims to OHIP
• A Pharmacy case fake Norvasc medication being
  dispensed to clients and the coroner
  investigating if this contributed to the deaths
  of multiple patients
• A Canadian pair who were charged over their fake
  Cancer clinic this affected over 800 patients
  in Mexico totaling 12 million dollars

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The Hospital Issue

• Canada Health Act
• Billing for semi-private coverage when no ward
  rooms available
• Patients are being implicated in the fight over
  funding

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Canadian Health CareAnti-Fraud Association

• 2006 Annual Conference
• Halifax, NS, Canada
• October 12 13, 2006

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Contacts

• Jeff Alcock, Chair
• Joel Alleyne, Executive Director
• Canadian Health CareAnti-Fraud Association
  (CHCAA)
• http//www.chcaa.org/
• phone [phone]
• e-mail info_at_chcaa.org