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Health Care Fraud: Whose Problem is it?

Health Care Fraud: Whose Problem is it?

  1. 1. Health Care Fraud: Whos Problem is it? Joel Alleyne Executive Director, CHCAAMassage Therapist Association Of Alberta September 24, 2011 Red Deer, Alberta
  2. 2. What is Fraud?A working definition: “Health care fraud is an intentional deceptionor misrepresentation that the individual or entitymakes knowing that the misrepresentation couldresult in some unauthorized benefit to theindividual, or the entity or to some other party.”(National Health Care Anti-Fraud Association) Three Key Elements: Intent – Misrepresentation – Purpose
  3. 3. Only a few actual types... Billing for Services Not Rendered Treating outside of Scope of Practice Allowing Unlicensed Persons to Treat Kickbacks or Referral Payments  If illegal Over-utilization/over treatment
  4. 4. Health Care Fraud - What Is It?Common Frauds:• Identity Theft• Fabricated Receipts• Misrepresented Claim Details• Unauthorized Alterations of Receipts 11
  5. 5. Other Fraud Schemes in Canada Double doctoring Office staff fraud Drug trafficking / diversion
  6. 6. Health Care Fraud contd “Health care fraud remains uncontrolled, andmostly invisible. … … this problem representsone of the most massive and persistent fiscalcontrol failures in their history.” “For those who profit from it, health care fraudis not seen as a problem, but as an enormouslylucrative enterprise, worth defendingvigorously.”Malcolm K. SparrowProfessor, Harvard University - Kennedy School of Government
  7. 7. Identity Theft “I used to work there” “I applied for a job there”“I dont even know that person”
  8. 8. Manage your Identity is about a “trusted identity” an “untrusted environment”
  9. 9. The ConsequencesPremium increasesDecrease in the quality of coverageInability to continue to provide insurance
  10. 10. Strategic Partnerships
  11. 11. Contact Us Canadian Health CareA Anti-fraud Association (CHCAA) Phone 416-593-2633 e-mail
  • NeehaParveen0708

    Apr. 13, 2014


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