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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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‘Too soon to celebrate’ Ottawa’s low case count, says Etches

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Ottawa Public Health (OPH) logged just 11 new cases of COVID-19 on Tuesday, the lowest daily total since Sept. 1.

Because of the lag between testing and reporting, the low number could simply reflect low turnout at the city’s testing sites on weekends — all month, new case counts have been lower on Tuesdays and Wednesdays. 

During a virtual news conference Tuesday, the city’s medical officer of health Dr. Vera Etches said she doesn’t read too much into a single day’s report.

“I don’t think we can make too much of 11. Actually, it could be a lot higher tomorrow — I would expect that, on average,” she said. “It’s too soon to celebrate.”

Provincewide, public health officials reported 1, 249 new cases Tuesday.

OPH also declared 62 cases resolved Tuesday, lowering the number of known active cases in the city to 462. Two more people have died, both in care homes currently experiencing outbreaks, raising the city’s COVID-19 death toll to 361. 

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Santa Claus isn’t coming to Ottawa’s major malls this year

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Santa Claus may still be coming to town this Christmas, but he won’t be dropping by any of Ottawa’s major malls, thanks to the COVID-19 pandemic.

On Friday, Cadillac Fairview said Santa won’t be making an appearance at any of its 19 malls across Canada, including Rideau Centre in downtown Ottawa. On Tuesday, Bayshore and St. Laurent shopping centres confirmed they, too, are scrapping the annual tradition.

“Due to the evolution of the situation in regards to COVID-19, we have made the difficult decision to cancel our Santa Program and Gift Wrap Program this year,” Bayshore spokesperson Sara Macdonald wrote in an email to CBC.

Macdonald said parent company Ivanhoé Cambridge cancelled all holiday activities “due to the rising number of COVID-19 cases across the country.”

Macdonald said families that had already booked an appointment to visit Santa will receive an email with more information.  

Virtual visits with Santa

Rideau Centre said based on customer research and discussions with public health officials, its North Pole is going online this year.

“Children will be able to have a private chat with Santa,” said Craig Flannagan, vice-president of marketing for Cadillac Fairview. “You’ll also be able to join a 15-minute storytime with Santa over Facebook Live.” 

At Place d’Orléans Shopping Centre, visitors are invited to take a “selfie with Santa” — actually, a life-size cutout of Santa Pierre, the man who’s been playing Santa at the east end mall for years.

“We understand that this is not ideal, but in lieu of this tradition we will be doing what we can to maintain and encourage holiday cheer,” according to a statement on the mall’s Facebook page.

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Ottawa Bylaw breaks up two large parties in Ottawa over the weekend

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OTTAWA — Ottawa Bylaw is investigating social gatherings of more than 10 people in private homes across Ottawa last weekend.

Mayor Jim Watson tells Newstalk 580 CFRA that Ottawa Bylaw broke-up two house parties over the weekend, with 20 to 25 people at each party.

“That’s the kind of stupidity that angers me, that’s where the bulk of the transmissions are taking place, if we exclude the tragedy of the long-term care homes; it’s these house parties with unrelated people,” said Watson on Newstalk 580 CFRA’s Ottawa at Work with Leslie Roberts.

“The message doesn’t seem to be getting through, particularly to some young people who think they’re invincible.”

In a statement to CTV News Ottawa, Bylaw and Regulatory Services Director Roger Chapman says, “There are still ongoing investigations from this past weekend that could result in charges.”

Chapman says recent investigations led to two charges being issued for social gatherings of more than 10 people in a private residence in contravention of the Reopening Ontario Act.

“In one case, up to 30 individuals were observed attending a house party in Ward 18 on Oct. 24,” said Chapman.

“The second charge was issued following a house party in Ward 16 on Oct. 31, where up to 16 individuals were observed to be in attendance.”

The fine is $880 for hosting an illegal gathering.

Alta Vista is Ward 18, while Ward 16 is River Ward.

Ottawa Bylaw has issued 24 charges for illegal gatherings since the start of the pandemic.

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