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CHCAA Fraud Prevention Best Practices

Best Practices for Healthcare Provider to fight insurance fraud within their clinic.

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CHCAA Fraud Prevention Best Practices

  1. 1. Healthcare Fraud:It’s Not My Problem, Is It? Canadian Health Care Antifraud Association
  2. 2. Canadian Health Care Anti-fraud Association VisionTo improve the Canadian Health Careenvironment by eliminating health carefraud.
  3. 3. Canadian Health Care Anti-fraud Association MissionOur mission is to combat health care fraudand assist in restoring the integrity of theCanadian health care system.
  4. 4. Membership
  5. 5. Health Care Fraud - What Is It?Three Key Elements:•Intent•Misrepresentation•Purpose 5
  6. 6. Health Care Fraud - What Is It?Common Frauds:•Identity Theft•Fabricated Receipts•Misrepresented Claim Details•Unauthorized Alterations of Receipts 6
  7. 7. Best Practices - Receipt StyleMinor Changes To Receipts Can Make a BigDifference!•Avoid hand-written receipt books•Add features that are hard to copy•Add colour•Be legible
  8. 8. Best Practices - Receipt DetailsMinor Changes To Receipts Can Make a BigDifference!•Always sign your receipts at time of treatment•Don’t let others sign receipts on your behalf.•Cheque writing controls•No spaces in front of digits•Spell out numbers•Label replacement receipts clearly as replacementswith the original receipt number
  9. 9. Best Practices - Receipt Details cont’dDetail, detail, detail! Accuracy, accuracy, accuracy!•More detail - less potential for alteration orfabrication •Detail service description •Exact amount charge •Amount charged if different from regular charge •Date of service (date of payment if different) •Patient name even if paid by someone else
  10. 10. Best Practices - Internal ControlDon’t Just Be a Great Practitioner - Be a GreatBusiness Person as Well!•Don’t leave signed receipts at front desk•Unique receipt numbers - record in treatmentrecord•Check front-office records•Be suspicious if front-office doesn’t want to sharedetails
  11. 11. Best Practices - Embrace AuditsMany an audit has uncovered fraud against aprovider!•Respond to audits yourself•Keep good records including receipt details andnumbers•Be wary of patients that ask that you don’t respondto audits or that you change details•Call the carrier if you have concerns rather thanrefuse to respond
  12. 12. Contact Us Canadian Health CareAnti-fraud Association (CHCAA) Phone 416-593-2633 e-mail