Ontario Provincial Police Anti-Rackets Branch has brought charges against a doctor whom they allege defrauded the Ministry of Health and Long Term Care for over $100,000. The OPP is accusing the MD of billing OHIP for services not rendered over a three-year period from 2005-2008.

The eight month investigation began after Police received a tip about the alleged fraud.

The OPP Anti-Rackets Branch Heath Fraud Investigations Unit works alongside the Ministry of Health’s Fraud Program’s Branch to detect and investigate cases of fraud against the public health care system in Ontario.

Source: Ottawa Citizen March 13, 2009

Recently, the City of Toronto (”the City”) announced that it has fired nine workers in relation to alleged health benefits fraud. The exact nature of the fraud is unclear as City has yet to disclose any further details surrounding the case. The most common types of employee benefits fraud include submitting false or altered claims for payment.

The fraud came to light after the benefit plan administrator, Manulife Financial, noticed something awry when they performed a random claims audit. These audits are an important part of the risk management and business integrity process for most health insurers.  By using various analytical tools such as data mining software, insurers are able to evaluate a cross section of claims for suspicious patterns of use.

In the Toronto Star article, the City stated employee benefits claims are not processed or reviewed by local management in order to protect employees’ privacy. Nevertheless, it attributed the initial failure to detect the fraud to a loophole in the system. This highlights the importance for any organization to conduct periodic fraud risk analysis to uncover potential weaknesses across all critical systems.

Source: Toronto Star – March 3, 2009