Fraud unit probes health billings
Special investigations opened into cases worth $1.4 million
JAMIE KOMARNICKI
CALGARY — A special government unit that investigates fraud in the medical system has opened 216 cases since late 2011 and looked into questionable billing worth $1.4 million, investigators say.
The special investigations unit within Service Alberta has also laid several charges in recent months, in cases ranging from patients illegally obtaining prescription drugs to a physician facing a fraud charge in a case currently before Edmonton court, government officials say.
Another nine cases involving investigations of doctors remain open, according to Service Alberta.
Since signing a memorandum of understanding just over two years ago with the Alberta Health team responsible for watching for improper billing, the investigative squad, which has the authority to lay criminal charges, has kept a relatively low profile.
Behind the scenes, the unit has doubled its ranks to four peace officers from the initial two-person team and opened dozens of case files delving into the complex world of billing system fraud, said Shelley Marsh, director of the Edmonton special investigations unit.
“We have the authority to investigate and charge those individuals,” Marsh said. “We see those files (through) from start to finish.”
Alberta’s fee-for-service health system has weathered criticism in the past over concerns there aren’t adequate controls to identify doctors and other practitioners who break the rules for billing.
In July 2011, following revelations a Calgary physician was claiming to see as many as 185 patients a day and billing for appointments with deceased people, Alberta’s auditor general called for better scrutiny.
Cases often begin with Alberta Health’s monitoring and investigations branch, which uses data-mining techniques to identify potential billing anomalies within the $3.4-billion Alberta Health Care Insurance Fund.
Since late 2011, that team has recovered roughly $6.1 million, according to Alberta Health spokesman Tim Wilson. Among those investigations, the team has recouped $2.5 million reviewing health service codes, he said.
It’s also worked on close to 400 “service provider compliance reviews,” recovering about $3.6 million, Wilson said in an email.
“Most of these reviews involve physicians, but can also involve other health-care practitioners or patients,” he said.
While the cases may be due to inadvertent errors navigating the correct billing codes, a red flag goes up when potential fraudulent activity is spotted, said Wilson.
That’s when the Alberta Health team calls in the Service Alberta special investigation unit.
“We’re new and it’s very specialized, so each case that comes to us is a new day, something different that we’re looking at,” said Hazel Ross, team lead for investigations.
According to Wilson, about 50 per cent of fraud reviews are related to people who aren’t eligible for coverage or an Alberta health card. Other reviews include prescriptions, identity theft and physician billing, he said.
Since January 2012, the special unit has laid charges against 17 people for offences including uttering a forged document, breach of trust, fraud, extra billing, double doctoring and trafficking of prescription medication, he said.
So far, the charges have led to two convictions for double doctoring, Wilson added.
Double doctoring, a type of “physician shopping,” involves patients visiting different offices to obtain multiple prescriptions for certain drugs prone to misuse, such as OxyContin and diazepam, without disclosing the previous appointments.
When tips come in, whether through the Alberta Health data mining team, law enforcement or even the public, the unit starts its review, said Ross.
A recent joint investigation with the Alberta Law Enforcement Response Teams led to the conviction of a Red Deer man for trying to amass and sell prescription drugs worth more than $100,000 on the street.
Another Canmore double doctoring file, a joint investigation with local RCMP in which close to 4,500 tablets and prescription drug capsules were found through a search warrant executed last month, led to charges against four residents for possession of a controlled substance for the purpose of trafficking.
Dr. Adam Poradzisz, meanwhile, is facing a charge of fraud over $5,000, in a case being heard in Edmonton court.
Marsh declined to comment on the case as it’s before the courts.
She stressed that the number of files opened involving physicians remains small, considering the province has about 7,000 doctors.
Investigations involving physicians are complex and can take up to a year, said Ross.
Alberta Medical Association spokeswoman Shannon Rupnarain said the group supports doctors who ask for help dealing with flagged claims or audits that come from Alberta Health, noting “the vast majority of Alberta physicians bill appropriately.”