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Medical insurance fraud widespread, as employees, providers rip off benefit plans

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Employers and their insurance providers are reeling at the proliferation of fraud rings — groups of employees that work together to abuse and exploit benefit plans, with medical services providers as their eager accomplices.

“You’re sitting in the lunchroom when a co-worker comes in and says, ‘I’ve got $1,000 worth of massage receipts, $2,000 worth of physiotherapy receipts, submit them all, and we can share the money,'” explains Gary Askin, a former commander with the Waterloo, Ont., police force who now works as a fraud investigator with Sun Life.

Cash, cash cards, purses, designer sunglasses, coats, and iPads are examples of what people have been able to get with fraudulent health benefit claims.

“They’ll say there’s no need to worry about getting caught, because they know the provider, and if the insurance company calls them, they will validate the claim.”

Askin refers to fraud ring organizers as “recruiters” and says the schemes can grow quickly, as employees reap rewards and spread the word.

Former police commander Gary Askin now works with insurance giant Sun Life, investigating cases of benefits fraud. (John Lesavage/CBC News)

“They rationalize it by saying ‘you didn’t get a raise last year,’ or ‘don’t worry, it’s just the insurance company’s money.’ They make some very compelling and convincing arguments.”

Sun Life estimates that 85 per cent of its fraud losses involve collusion with a medical services provider.

Clinics that offer massage, physiotherapy, orthotics and compression stockings are most commonly used. Sun Life “delisted” a whopping 1,500 providers across Canada last year alone, after proving they had been involved in false claims. Claims from those clinics are no longer accepted.

“You’re stealing from your employer,” says Dave Jones, Sun Life’s head of group benefits. “You are stealing from the wallet of money, if you can think of it that way, that’s used to pay for your health care, and the health care of your family, and the health care of your friends and colleagues at work.”

The industry association has recently launched a public awareness campaign called “Fraud=Fraud,” to educate Canadians about the problem. The website features a link to a page of email addresses and phone numbers, where suspected cases can be reported to authorities.

An image from the CLHIA’s public education campaign. Many employees don’t realize that criminal charges as well as termination of employment can be among the consequences of benefits fraud. (CLHIA)

One case that made headlines in 2018: the Toronto Transit Commission fired 250 employees after discovering they were all involved in a scam related to orthotics. The service provider — who facilitated the entire escapade — has been sentenced to two years in a federal penitentiary plus three years on probation.

Meanwhile, a Toronto firefighter was sentenced to six months in jail for submitting $32,000 in forged receipts. A professor at York University appealed her firing after falsifying invoices for $8,000 worth of massage and physiotherapy, but lost.

How it’s done

A typical scam might involve compression stockings. The fraudulent provider is aware that a particular company’s benefit plan will cover four pairs in a year, at a cost of $220 each.

When an employee arrives with their prescription, the provider presents a new and enticing offer: pay for all four, submit the receipt and be reimbursed in full by the benefit plan — but receive just one pair of compression stockings and collect some “incentives” on the side.

Insurer Green Shield Canada sent an undercover investigator into one such meeting in an Ontario city last August to pose as an employee. She recorded the meeting with a hidden camera.

“I can give you the website, you can choose what kind of shoes,” the provider tells the investigator, who selects a pair of Ugg boots.

“Show it to your husband too, OK?” he adds, well aware that the plan will also cover a spouse’s medical needs as well.

Sun Life’s Dave Jones says the company’s fraud team includes close to 100 investigators, some of them former police officers, others are data scientists. (Ed Middleton/CBC News )

Green Shield’s Brent Allen says providers often encourage scam participants to max out on their plans’ provisions. He’s seen employees collect all manner of goods.

“We wouldn’t think it’s acceptable to steal from our employer outright,” he says.

“If you saw somebody walking out with an iPad that the employer had bought, you would be offended by that. Then why is it OK to go to a provider and get an iPad that that employer paid for?”

Life and death decisions

Allen attributes the fraud epidemic to greed.

“There’s a lot of money in our industry,” he says. “People are going to want to take pieces of it.”

In total, private insurers paid out $34 billion in health claims last year, according to the Canadian Life and Health Insurance Association (CLHIA). Estimates for the number of fraudulent claims range from two to 10 per cent, meaning between $600 million and $3.4 billion is being stolen annually.

Those costs can be paid indirectly by honest, innocent employees.

“There are life-saving drugs available under these plans that can cost hundreds of thousands of dollars,” Allen points out.

And employers can’t afford to be paying hundreds of thousands of dollars for claims that aren’t real when they have somebody truly in need. It’s forcing employers to make decisions about whether they cover expensive drugs that could be the difference between somebody living or dying, working or not working.”

Data and artificial intelligence

The CLHIA’s public awareness campaign includes advertising on Facebook, LinkedIn and Twitter. A professionally produced commercial shows an employee being escorted out of the office by security with a box of their belongings, while shocked co-workers stand and stare.

“You were appreciated and liked, soon to be rewarded with a promotion and raise. But you threw it all away,” intones a sombre voice-over. “So if you’re thinking about falsifying your health or dental claim, think again.”

But as schemes become more sophisticated, so do detection methods. Green Shield uses an artificial intelligence program to spot fraudulent claims. Sun Life has a team of almost 100 investigators, using special software to make connections between suspicious clinics and employees using them.

“These are resources I would’ve died for in policing,” says investigator Gary Askin. “We’ve got more data scientists working for Sun Life than any police service in the country, with the exception possibly of the Mounties.”

The industry association hopes its awareness campaign will generate a number of tips regarding cases of suspected fraud. The message they’re trying to send is clear: if you’re not prepared to do the time, don’t do the crime.

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List of Tourist Attractions Open Now in Ottawa

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With Ontario now in Step 3 of 2021 three-step plan for reopening, museums and other indoor attractions are allowed to reopen with capacity limited to not exceed 50 per cent capacity indoors and 75 per cent capacity outdoors.

Here is a list of Ottawa attractions you can visit starting July 16th.

Do remember to wear masks and buy tickets in advance.

Parliament Hill

Parliament’s Centre Block and Peace Tower are closed for renovation.

You can join for tours of the Senate of Canada Building (2 Rideau Street), House of Commons at West Block (111 Wellington Street) on Parliament Hill, and East Block at East Block (111 Wellington Street) on Parliament Hill.

When: Grounds open; guided tours of Parliament are suspended through the summer of 2021.
Where: 111 Wellington Street, Downtown Ottawa

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Ottawa performer leapfrogs from gymnastics to Broadway to TV

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A new AppleTV+ series set in a magical town that’s stuck in a neverending 1940s musical includes a pair of Ottawa siblings in the cast. 

Warren Yang and his sister, Ericka Hunter, play two of the singing, dancing residents of the village portrayed in Schmigadoon!, a small-screen series that takes its cues from classic musicals like Brigadoon, Wizard of Oz and Sound of Music, and skewers them with the offbeat comedic mastery of Saturday Night Live. 

In fact, you’ll recognize many of the names from SNL, starting with executive producer Lorne Michaels, creator of the late-night, live-comedy sketch show. Schmigadoon! also stars SNL cast member Cecily Strong and comedian Keegan-Michael Key, who hosted SNL in May. They play a New York couple who get lost on a hike and stumble into a strange town where everyone sings and dances. 

For Yang, a relative newcomer to show-biz, the series marks his television debut. For Hunter, the younger of his two older sisters, it’s the latest in a career path that began with dance lessons as a child more than 30 years ago. She attended Canterbury High School, Ottawa’s arts-focused secondary school. 

“Her dream was always to perform,” said Yang, 34, in an interview. “But that was never the path I thought was an option for me.” 

While his sister studied dance, Yang did gymnastics. He was an elite gymnast throughout his youth, ultimately leaving Merivale High School at 16 to train in Montreal, finishing high school through correspondence courses. He was a member of the Canadian National Team and received a scholarship to study at Penn State, majoring in marketing. 

A few years after graduation, Yang was working at an advertising agency in Toronto when he got a call from a Manhattan number. To his astonishment, they asked if he would be interested in auditioning for a Broadway revival of Miss Saigon.

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COVID-19: uOttawa to require vaccination for students living in residence

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Vaccination will be mandatory for students who want to live in residence at the University of Ottawa this year, with proof of vaccination and at least one dose required before move-in, or within two weeks of doing so if they can’t secure a shot before arriving.

Those who can’t receive a vaccine for “health-related reasons or other grounds protected under the Ontario Human Rights Code” will be able to submit a request for accommodation through the university’s housing portal, according to information on the university’s website.

Students with one dose living in residence will also have to receive their second dose “within the timeframe recommended by Ottawa Public Health.”

People who haven’t been granted an exemption and don’t get vaccinated or submit proof of having done so by the deadlines set out by the school will have their residence agreements terminated, uOttawa warns.

“Medical and health professionals are clear that vaccination is the most (effective) means of protecting people and those around them,” reads a statement provided to this newspaper by uOttawa’s director of strategic communications, Patrick Charette.

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“It is precisely for this reason that the University of Ottawa is requiring all students living in residence for the 2021-2022 academic year to be fully vaccinated. The University recognizes that some students may require accommodations for a variety of reasons and will be treating exceptions appropriately.”

Faculty, staff and students are also strongly encouraged to get vaccinated, the statement notes.

“Ensuring a high vaccine coverage in all communities is critical to ensuring an ongoing decline in cases and ending the pandemic. This will be especially important with the return of students to post-secondary institutions in our region in the fall of 2021.”

Neither Carleton University nor Algonquin College is currently mandating vaccination for students living in residence, according to the websites for both schools. But uOttawa isn’t alone in its policy – Western University, Trent University, Durham College and Fanshawe College have all implemented similar requirements. Seneca College, in the GTA, is going even further, making vaccination mandatory for students and staff to come to campus, in-person, for the fall term.

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