Your role in the detection of health care fraud and benefit plan abuse

Your role in the detection of health care fraud and benefit plan abuse

Disclaimer I am speaking today in my individual capacity. The views and opinions presented are entirely my own. They do not necessarily reflect the views of the Alberta Blue Cross; Nor should they be construed as an official explanation or interpretation.

What is fraud? The Canadian Health Care Anti-Fraud Association (CHCAA) states: Fraud is the intentional deception or misrepresentation that an 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. Health care fraud refers to fraud committed against an individual or organization operating within the health care system. Fraud is a criminal offence under section 380 of the criminal Code of Canada and is punishable by up to 14 years in prison.

Today s presentation Facts about health care fraud in Canada What does health care fraud or plan abuse look like? What can we do to detect it and help prevent it as: Benefit plan managers Pharmacy health care providers Benefit recipients

Health care fraud in Canada It is estimated that 2 to 10 per cent of every health care dollar in North America is lost to fraud. (The Canadian Health Care Anti Fraud Association) In Canada over $120 billion dollars is spent annually on health care. Meaning the cost of health care fraud could surpass $12 billion each year. (The Canadian Health Care Anti Fraud Association) Health care fraud can be perpetrated by virtually any user of the health care system, such as patients, health care providers, staff and administrators.

What is health care fraud or plan abuse? Identity theft False billing

What is health care fraud or plan abuse? (continued) Forgery or alteration of documentation Claiming for more service than was actually provided Double doctoring

What is health care fraud or plan abuse? (continued) Misrepresenting services Providing services not covered and claiming for them as services that are covered. Masquerading as health care professionals Delivering health care services without proper licenses.

What activities can a benefit plan manager take to ensure plan viability? Claims adjudication edits Provider communication bulletins

What activities can a benefit plan manager take to ensure plan viability? (continued) Post-claim verification Member confirmations Provider compliance audits

Preventative action you can take as a pharmacy service provider Ensure the patient you are submitting claims for has a valid benefit coverage and that your records match what is on their health benefit cards. Understand the claiming policies and procedures defined by the various benefit plan administrators and Provincial and Federal benefit programs. Use the response codes provided to you when submitting direct bill claims to help detect potential benefit fraud.

Preventative action we can all take Be cautious of co-payment waivers, advertisements stating covered by insurance or proposing services because they are covered by insurance rather than based on need. Treat your health benefits card as being as valuable as a credit card. Closely examine your Explanation of Benefits (EOB) to ensure all products or services billed to you were the services received when you or a member of your family, visited a health care provider.

Preventative action we can all take Know your benefits policy. If you do not have a copy of your policy ask your employer or for a copy. Review it and if necessary ask for assistance to ensure you have a thorough understanding what you are or are not entitled to. When you suspect fraud REPORT IT!

Canadian Health Care Anti-Fraud Association Who are they? The Association was founded in 2000 to give a voice to the public and private sector health care organizations interested in preventing fraud in the Canadian health care environment. Membership is open to organizations an individuals responsible for the detection, prevention, investigation and prosecution of health care fraud. Its mission To combat health care fraud and assist in restoring the integrity of the Canadian health care system.

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REFERENCES The Canadian Health Care Anti-fraud Association (CHCAA) http://www.chcaa.org/aboutus.php Alberta Blue Cross fraud prevention https://www.ab.bluecross.ca/fraud.html