Health fraud rampant
Survey finds false and inflated claims costing $3B to $10B a year
NIAGARA FALLS, ONT. •
Canada’s health care system is rife with fraud that costs the public and private sectors an estimated $3-billion to $10-billion a year, the country’s first-ever survey of health fraud indicates.
“ It’s a big problem. It’s a multibillionproblem and that’s a big drain on the health care system,” said Michael Chettleburgh of Fraudbox Inc., which did the survey for the Canadian Health Care Anti-Fraud Association.
“If we could claw back a billion, $2-billion a year [from fraud] and invest that money in MRI machines, would that affect you as a health care consumer? I would suggest it does,” Mr. Chettleburgh said.
Speakers at the anti-fraud association’s annual conference told about fraudulent billings by pharmacists, dentists and other health care professionals, as well as the growing problem of people stealing caregivers’ identities to illicitly claim payments.
Joel Alleyne, the association’s executive director, estimates the extent of fraud at between $3-billion and $10-billion a year.
“It’s affecting your medical benefits: You’re not able to get in to see the professional you want to,” said Bob Whitman of the Insurance Bureau of Canada.
More than 100 players in the field responded to the survey, including almost 80 who represent the insurance companies and government agencies and departments that make payments to health care providers. Others were police or investigators in the field.
Almost 95% of providers said their organization had been hit by fraud in the previous year, with half recording 30 or more incidents.
All respondents estimated at least 3% of claims were fraudulent, while about seven out of 10 pegged the prevalence of the problem at 6%- 19%.
It represents a huge sum as a percentage of the $ 130- billion spent annually on health care in Canada, Mr. Chettleburgh noted.
The most commonly cited form of fraud in the survey was billing for services never provided. Others included performing unnecessary care, misrepresenting non-covered procedures as necessary and billing for services provided to a fictitious patient.
But 42% of respondents said the commitment to fighting fraud in their organizations was not very good or poor.
About half spent less than $ 250,000 on the task, though their fraud losses are likely in the millions.
The study indicated that insurance companies and medicare administrators who dole out money generally spend a pittance on combatting fraud, partly out of fear about negativity publicity.
Most of those surveyed said government should make health care fraud a more serious criminal offence and urged more stringent sentencing.
A new twist on the problem appears to be people who make fraudulent claims under the stolen name of real health care practitioners, or simply make up identities.
Bob Whitman of the Insurance Bureau of Canada related the case of a nurse who was stripped of her licence by the Ontario College of Nurses after being convicted of theft.
As she filed claims for rehabilitation services, she adopted a number of identities, eventually using the name and registerednurse number of her sisterin- law, who is also in the profession, said Mr. Whitman.
The IBC investigators identified more than $ 200,000 in fraudulent billings involving 100 patients she was unqualified to treat, he said.
“ She was collecting a lot of money,” Mr. Whitman said, showing a photograph of the woman’s sprawling, three- cargarage home.
He said his office have identified another four cases of identity theft involving health care professionals.
But health care fraud appears to be even more insidious in the U.S.
Ludmila Reigel, an FBI special agent, described bureau operations against Eastern European organized crime groups who co- opt doctors, other professionals and patients in largescale fraudulent billings for services.
In one case involving Armeniancriminals, even a bank CEO was paid off to help the fraudsters launder their proceeds, said Ms. Reigel.
National Post tblackwell@ nationalpost. com