The Canadian Health Care Anti-fraud Association

1. The Canadian Health CareAnti-fraud Association Joel Alleyne, Executive Director Canadian Pension & Benefits Institute – Premier Forum Winnipeg, MB June 15, 2007

2. 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

3. Canadian Health Care Anti-fraud Association Vision • To improve the Canadian health care environment by eliminating health care fraud.

4. 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.

6. 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

7. 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

8. 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)

9. “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 America’s Health Care System”

10. 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

11. 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

12. 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

13. 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

14. Fighting Health Care Fraud cont’d 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

15. 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

16. Fighting Health Care Fraud cont’d 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

17. 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

18. 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

19. 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

21. 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

22. Canadian Health CareAnti-fraud Association 2007 Annual Conference Toronto, Ontario Canada September 20-21, 2007 Hilton Toronto Airport

23. Contacts • Scott Moore, Chair • Joel Alleyne, Executive Director Canadian Health CareAnti-fraud Association (CHCAA) http://www.chcaa.org/ phone 416-593-2633 e-mail info@chcaa.org