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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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Future of Ottawa: Chefs with Kathryn Ferries

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This week in the Future of Ottawa series, we’re taking a deep dive into the bar and restaurant industry—what it’s like now and where it’s headed. Read on for a guest post from Kat Ferries on the future of chefs, or read posts from Quinn Taylor on bars or Justin Champagne on fine dining.

Kat Ferries is Sous-Chef at Stofa Restaurant and a 2020 San Pellegrino North American Young Chef Social Responsibility Award Winner.

Apt613: What is the current landscape for chefs in Ottawa?

Kat Ferries: There is such great talent in Ottawa with so many chefs either being from here originally or have returned after traveling and have since opened some incredible restaurants. Many chefs have focused menus that really highlight their strengths, their heritage, and their passion for food. Dominique Dufour of Gray Jay, Marc Doiron of Town/Citizen, Steve Wall of Supply & Demand, Daniela Manrique Lucca of The Soca Kitchen, and so many more are all cooking up beautiful and delicious food in this city.

If you care to make a prediction… Where is the food industry in Ottawa going for chefs in 2021?

The industry right now is, unfortunately, in a really tough spot. The pandemic has been so devastating on mental, physical and emotional levels for so many and I know that many of my friends in this industry are burning out. There are many discussions happening on work/life balance and what is healthy for everyone. Some may never return to the long, hard hours we are expected to put in day after day and instead opt for a more flexible schedule or hire more staff to lighten the load on everyone, with some even leaving the industry indefinitely. Some may throw themselves back into this industry 10x as hard and create some of the best restaurants and concepts we’ve yet to see. I think all that will happen after the pandemic though.

For this year, it’s mostly about survival and finding happiness in creating what we can in the spaces we have while following all the laws and guidelines from public health officials. I think we will see more chefs creating experiences for guests that we otherwise wouldn’t have: think pop-ups, virtual dinner clubs, cocktail seminars, collabs, etc.

Where in your wildest dreams could the Ottawa culinary community grow in your lifetime?

I would love to see the Ottawa community support more small, local restaurants so our streets are bustling late into the nights like they are in Montreal, New York, or Europe. Having a local restaurant to frequent should be so much more commonplace, where you can enjoy a night out more often than just Friday or Saturday night. I would also love to see many more of our local chefs highlighted for the amazing food they create!

What is the best innovation to take place in your industry since the pandemic started affecting Ottawa?

Turning all our restaurants into mini-markets for customers to enjoy the food and wine of their favourite places at home. We have bottle shops for all your wine, beer and cocktail needs as well as menus that reflect what each restaurant does best. Some have even pivoted to a point where they are 100% a store and have paused any type of “service-style” dining.

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Future of Ottawa: Fine Dining with Justin Champagne

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This week in the Future of Ottawa series, we’re taking a deep dive into the bar and restaurant industry—what it’s like now and where it’s headed. Read on for a guest post from Justin Champagne on the future of fine dining, or read posts from Kathryn Ferries on chefs or Quinn Taylor on bars.

Justin Champagne went to culinary school at Northwest Culinary Academy of Vancouver. He got his start in fine dining restaurants at C Restaurant under Chef Robert Clark, then at Hawksworth Restaurant under Chef Eligh. He staged at three-Michelin-starred Atelier Crenn under Chef Dominque Crenn before moving to Ottawa and spending five years at Atelier, working his way up to Sous-Chef. He’s now the Head Chef of Bar Lupulus.

Apt613: What is the current landscape of fine dining restaurants in Ottawa?

Justin Champagne: Ottawa punches well above its weight class when it comes to quality restaurants in general. Fine dining is no exception to that—we have some amazing chefs here that are doing really great things. We also have some phenomenal sommeliers in town that are a huge factor when it comes to a guest’s experience in a fine dining restaurant. While there are some fantastic fine dining restaurants in town I do believe there’s room for more, and definitely room for more creativity and unique styles of cooking! I think we’ll see more small fine dining restaurants opening up, “micro-restaurants” where there’s maybe 20 seats. This will be over the next few weeks as the industry did take a big hit financially with COVID-19, but we still have a lot of great young chefs who have the fire inside of them to open their own location!

If you care to make a prediction… Where is fine dining going in Ottawa in 2021?

I’m not sure it’ll be 2021 or 2022 with the way the vaccine rollout and stay-at-home order is going, but I do expect there to be a wave of people looking to go out to fine dining restaurants. We’ve been cooped up cooking for ourselves or ordering takeout for over a year now. People are getting antsy and ready to go out and have fantastic meals again with exceptional wine and not have to worry about doing all the dishes afterwards!

Where in your wildest dreams could fine dining go in Ottawa in your lifetime?

That’s the fun part about “fine dining,” it can go anywhere and it can mean many things. Fine dining is about amazing service and well thought out, unique food that the kitchen spent hours fussing over, being meticulous in execution. Outside of that, you can have a lot of fun and be creative in different ways. My wildest dream I guess is that fine dinning restaurants begin to thrive and are able to charge without backlash the kind of prices that they need to charge in order to keep the lights on and pay their staff a proper living wage!!

What is the best innovation to take place in your industry since the pandemic started affecting Ottawa?

I’m not sure if I would really say there’s been a best “innovation” in my industry during the pandemic, but I will say that seeing the “adaptability” by all the restaurants in Ottawa has been incredibly inspiring. Ottawa’s food scene has always been a tight-knit community, “everyone helping everyone” kind of mentality. And this pandemic has really helped show that—restaurants helping restaurants through all of this!

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Ottawa’s Giant Tiger chain celebrating 60 years in business

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OTTAWA — An Ottawa staple, along with what might be the most famous cat in Canada, are celebrating a milestone Monday.

Giant Tiger is 60 years old.

“It all started with a very simple idea,” says Alison Scarlett, associate VP of communications at Giant Tiger. “Help Canadians save money every single day. Bring them products that they want and need. When you focus on those core principals, it really is quite simple to succeed.”

In 1961, Gordon Reid opened the first Giant Tiger in Ottawa’s ByWard Market. The company now has more than 260 locations across Canada and employs roughly 10,000 people.

“If you were at our store on opening day 60 years ago, the in store experience would be a little bit different from your local Giant Tiger store today. So that’s changed. A lot of our products and offerings have changed or expanded as Canadian consumers wants and needs have changed or expanded,” says Scarlett.

The homegrown department store continues to be a favourite for many shoppers looking to for the best deals on everyday products.

Helen Binda has been shopping here for decades.

“Many years. I can’t remember when. I’ve always loved Giant Tiger. It’s always been a good store for me.”

“I think its amazing and I think that we need more department stores,” says shopper Fay Ball. “And if it’s Canadian, all the better.”

The Canadian-owned family discount store carries everything from clothing to groceries, as well as everyday household needs. They’ve also expanded their online store and like most retailers provide curbside pickup during the pandemic.

“Doing what is right for our customers, associates, and communities. That has enabled us to be so successful for all of these years,” says Scarlett.

To celebrate, Giant Tiger is hosting a virtual birthday party at 7 p.m. Monday with live musical performances from some iconic Canadian artists.

You can visit their Facebook page to tune in. 

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