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Healthcare Fraud:
It’s Not My Problem, Is It?

           Canadian Health Care Antifraud Association
Canadian Health Care Anti-fraud
                      Association

                Vision

To improve the Canadian Health Care
environment by eliminating health care
fraud.
Canadian Health Care Anti-fraud
                       Association

                  Mission
Our mission is to combat health care fraud
and assist in restoring the integrity of the
Canadian health care system.
Membership
Health Care Fraud - What Is It?

Three Key Elements:

•Intent

•Misrepresentation

•Purpose




                              5
Health Care Fraud - What Is It?

Common Frauds:

•Identity Theft

•Fabricated Receipts

•Misrepresented Claim Details

•Unauthorized Alterations of Receipts


                                        6
Fraud Myth #1

“Canada Doesn’t Have a Fraud Problem!”
Where there is money, there is someone that wants
to get that money even if not entitled
No verifiable statistics but studies suggest could be
3% of healthcare dollars which could mean over $4
billion of the over $135 billion in public healthcare
expenditures may be fraud
Excludes private payor and patient out-of-pocket dollars




                                                           7
Fraud Myth #2

“The Insurance Company Just Doesn’t Want to Pay
The Claim!”
Insurance carriers are obligated, contractually and
legally, to process claims as your patient’s
employers directs them


Increasing utilization of benefits, especially in tight
economic times, forces your patient’s employers to
make tough decisions about what they can offer in
employee benefit plans
Fraud Myth #3

“Insurance Carriers Always Think It Is the Provider
Committing Fraud!”


Absolutely Not! The carriers have seen so many
types of fraud by so many different people that they
do not assume anything.
Fraud Myth #4


“I’d Know It If Someone Pretended to Be Me!”

The Fraudster will do everything possible to make

sure that doesn’t happen.
Fraud Myth #5

“The Insurance Company Will Recognize If They
See a Different Receipt For Me.”


Millions and millions of claims are processed in
Canada each year


More and more claims are processed electronically
without being viewed by a person


Would cause massive delay in claim payment to
check receipts
Fraud Myth #6

“My Patient Wants Me to Use a Different Date on
The Receipt, What’s The Harm?”


Different date, different patient, different service - no
difference - misrepresentation


Knowingly issuing a false document may result in
criminal charges.
Fraud Myth #7

“My Patient Would Never Change My Receipts!”


Altered receipts are not uncommon.


There are things you can do to reduce this potential
Contact Us

     Canadian Health Care
Anti-fraud Association (CHCAA)

      http://www.chcaa.org/
   Phone 416-593-2633
  e-mail info@chcaa.org

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Healthcare Fraud: It's Not My Problem, Is It

  • 1. Healthcare Fraud: It’s Not My Problem, Is It? Canadian Health Care Antifraud Association
  • 2. Canadian Health Care Anti-fraud Association Vision To improve the Canadian Health Care environment by eliminating health care fraud.
  • 3. Canadian Health Care Anti-fraud Association Mission Our mission is to combat health care fraud and assist in restoring the integrity of the Canadian health care system.
  • 5. Health Care Fraud - What Is It? Three Key Elements: •Intent •Misrepresentation •Purpose 5
  • 6. Health Care Fraud - What Is It? Common Frauds: •Identity Theft •Fabricated Receipts •Misrepresented Claim Details •Unauthorized Alterations of Receipts 6
  • 7.
  • 8. Fraud Myth #1 “Canada Doesn’t Have a Fraud Problem!” Where there is money, there is someone that wants to get that money even if not entitled No verifiable statistics but studies suggest could be 3% of healthcare dollars which could mean over $4 billion of the over $135 billion in public healthcare expenditures may be fraud Excludes private payor and patient out-of-pocket dollars 7
  • 9. Fraud Myth #2 “The Insurance Company Just Doesn’t Want to Pay The Claim!” Insurance carriers are obligated, contractually and legally, to process claims as your patient’s employers directs them Increasing utilization of benefits, especially in tight economic times, forces your patient’s employers to make tough decisions about what they can offer in employee benefit plans
  • 10. Fraud Myth #3 “Insurance Carriers Always Think It Is the Provider Committing Fraud!” Absolutely Not! The carriers have seen so many types of fraud by so many different people that they do not assume anything.
  • 11. Fraud Myth #4 “I’d Know It If Someone Pretended to Be Me!” The Fraudster will do everything possible to make sure that doesn’t happen.
  • 12. Fraud Myth #5 “The Insurance Company Will Recognize If They See a Different Receipt For Me.” Millions and millions of claims are processed in Canada each year More and more claims are processed electronically without being viewed by a person Would cause massive delay in claim payment to check receipts
  • 13. Fraud Myth #6 “My Patient Wants Me to Use a Different Date on The Receipt, What’s The Harm?” Different date, different patient, different service - no difference - misrepresentation Knowingly issuing a false document may result in criminal charges.
  • 14. Fraud Myth #7 “My Patient Would Never Change My Receipts!” Altered receipts are not uncommon. There are things you can do to reduce this potential
  • 15. Contact Us Canadian Health Care Anti-fraud Association (CHCAA) http://www.chcaa.org/ Phone 416-593-2633 e-mail info@chcaa.org