November 9, 2001

Introducing the Canadian Health Care Anti-Fraud Association

The Canadian Health Care Anti-Fraud Association (CHCAA) is a new organization of public and private payers, and law enforcement who welcome membership from the regulated profession associations and colleges. With representation from across Canada, the CHCAA’s mission is to “combat health care fraud and assist in restoring the integrity of the Canadian health care system”.  Our organization members focus upon the broad health care network and the consumer/patient, network systems, health care professionals and regulators who deliver the health care business services.  The health care networks and broad stakeholders (public payers, private payers, employers and the public consumer) depend upon the regulations to invoke governance structures supporting health care accountability and integrity.

Regardless of whether health care is provided by public or private plans, the taxpayer base (e.g. the employer, employee or general public) pays for unethical health care business practices.  While 70 percent of the health care funds are dispensed by publicly funded health care, 30 percent is dispensed by private health care insurance for disability, extended health care and dental care programs.  The cost of health care fraud is not calculatable by definition, but the damage of unethical health care practices affects all taxpayers, whether it is by misuse of valuable health care dollars or abuse of personal health record history.

Response To the Ontario HPRAC Submission

Our Association is very pleased by the work of the Ontario Health Professions Regulatory Advisory Council and by the direction of recommendations submitted.  We support the suggestions and recommendations made in the Review of the Regulated Health Professions Act, particularly those that improve the complaints and disciplinary processes of the Colleges providing: 1) easy access, 2) understandable and easy to follow consistent protocols, 3) meaningful, behaviour changing consequences for the professionals who breach public trust. 

However, we feel that there is a need for the health practices legislation to go further in addressing the evolving health services business world.  In the current world, trust systems are required to provide timely responsive health services. The health professions need to accept the responsibility to manage breaches of ethics and trust with not just the patient, but also the health care system funders. Collectively, we have a fiduciary responsibility for the system. 

Fraudulent health care billing practices victimize the public in many ways, including:

§         The cost to consumers not only in improper treatments or falsely consumed health care dollars, but also in the breach of respect and privacy for patient records, and breach of trust between the provider and the provincial and private health care funders.

§         The increased risk of physical harm due to medically unnecessary treatments.

§         The difficulty to obtain benefits when incorrect or fraudulent records have exhausted benefits.

§         The increased cost of health care funding by consumers, employers and provincial taxpayers.

The Ontario health care regulations do give specific emphasis to practice concerns such as sexual abuse.  We wish to acknowledge this is a valid concern, however, health care fraud deserves special attention in its own right. The inability to effectively manage the unethical business practices of health care professionals is likewise a major societal problem. 

Our experience in dealing with the different Colleges is that there is a very inconsistent interpretation and compliance with the “spirit and intent” of the Regulated Health Professions Act, and there is a need for more definition of internal profession quality assurance, disciplinary processes, and fraud prevention requirements, such that all Colleges can measurably rise to the same level of commitment. 

The health care payers depend upon the regulatory environment for important benefit eligibility information including:

1.        Timely data regarding the professional standing of health care providers submitting service claims.

2.        The right to verify that billed services are valid and reasonable health cares services.

3.        Education of the profession membership on professional business ethics and practices.

4.        Governance supporting cost efficient public and private health plans.

We believe in minimizing bureaucracy and cost of regulation in the health care system, but we believe that the professions must be held accountable for setting and ensuring ethical health care system business practices. Our key concerns are summarized below:

Issue #1: Recognize Public and Private Payers as Stakeholders

·         We feel that there should be a definition placed upon “public” which acknowledges the existence of a third party stakeholder in the health care model, the public and private payer.  While the relationship between the patient and health care professional should continue to be “paramount”, it is necessary to acknowledge the role of the third party funders in the health care model with an explicit right to verify the health care service bill.

·         Public and private payers are both important stakeholders in the health care system.  Over 30% of health care services are privately funded by employers, with special emphasis upon supplementary health and workers compensation benefits not covered at all by provincial health plans for the working public. Public and private payers are an integral part of the health care funding system, with key dependency upon the regulatory environment for open access to professional practice status information from regulators.

Issue #2: Need to address health care business governance

·         Public and private payers are the “front line” that administer health service bills from professionals or via patients seeking reimbursement for disbursements made earlier.  In order to monitor and regulate the ethical practice of professionals, the health professions require this information to use in analyzing unusual statistical anomalies. This is an extremely valuable tool.  We would like to move to a model where statistical practice inputs from the payers are a core component of assessing professional practices to expected health care models.  An exemplar can be found in the relationship established between the BC College of Dentistry and the Private Payers in the eighties – where data is provided and acted upon by the colleges.

·         Public and private payers need to be part of ongoing consultation processes with the health professions, consumer public, particularly regarding the ongoing financial health and stewardship of the system.

·         The RHPA must embrace the changing technology and health care delivery environments, and accept a more open health care system “business” with interfaces between health professions, regulators, payers and the public.

·         There is a need for a health care complaints system that recognizes the necessity for reporting responsibilities from payers, similar to that required for financial services professionals. This model would permit payers to become an “official” complainant or reporter of specific health care business ethics breaches, and be held harmless when acting in good faith.  These rules need to consider that substandard practice can include situations where there is a “balance of probability” that health service transactions are implausible, materially contrary to expected medical practices, while false transactions generating false health records should be considered serious.

·         This requires a right of access to practitioner standing records in “real time”.  Payers need the explicit right to verify health care professional records backing billing transactions without additional patient release if the professional submitted the transaction to the payer or its assigned agents for payment, or if the patient has provided the payer with the release to view their medical records. Our focus is on verification of billing activities rather than on gaining access to medical records or to questioning the medical condition. Under current electronic communication systems, this is an existing right.

Issue #3: Strengthening of Quality Assurance Programs

We agree with the need for stronger Quality Assurance programs.  Subjecting Colleges QA programs to independent review would help to ensure the spirit and intent is followed.  The system needs openness on the scope of programs and methodology.  We believe that there is an opportunity to establish and document common QA objectives for all Colleges, including:

§            Scope

§            Methodology

§         Types of inputs required

§         Types of processes supported

§            Sources of input and feedback required for quality assurance program to function

§            Responsibility for reporting to stakeholders

 

There is currently a lack of assurance provided to payers that proactive QA programs are effective. This is a key support for trust between stakeholders.  At present, practice billing information is not encouraged, solicited, or required to be used by the Colleges to obtain assurance that professionals are acting in public best interest.  Payers would be willing to contribute to a public health care provider activity database which would permit use of non-personal practice information. This would allow colleges to monitor both over and under servicing of patients.  Unless there is more collaboration between payers and regulators on this aspect, any quality assurance program will be very limited in scope and public effectiveness.  There should be openness of the quality assurance results to support stakeholder confidence in profession compliance standards.

Issue #4: Healthcare Fraud and Abuse Prevention Programs

This is an important part of regulatory framework required to maintain a viable health care delivery system. Much of the health care framework was establish by professionals for payers, but there was not a governance system or climate created.  We recommend that each college be required to institute fraud prevention programs, including:

·         Code of Member Ethics

§            General abuse and fraud

§            False health record creation

·         Fraud Prevention Policy for each College

·         Documented program within each College stating how it is working to address healthcare fraud

§           Including member and public education

§            Industry networks and commitment.

·         A requirement for clear documentation and communication regarding situations deemed to be abusive, fraudulent, or disallowed practices.

§            Conflicts of interest

§            Treating and billing for family members

§            Having undeclared ownership interest in treatment facilities

·         Kickbacks

·         False representation of patient

·         Not applying co-payments

It should be made clear that collaboration with public and private payers, law enforcement and the public to combat fraud has no conflict of interest and is a requirement for the Colleges. Colleges must establish a structure of consistent penalties. They need to institute minimum penalties for creating false health records, criminal activities by improperly supervised office workers, and for false billing.

 

Communication of disciplinary actions within 24 hours of the decision using methods such as:

§            On the Colleges’ websites to public

§            An electronic mailing with open recipient sign-up listing

As payers are industry sentinels, disciplinary information should be mandated for communication within 24 hours, electronically, to all Canadian payers (public and private).

Issue #5: Public Appointees

We agree with the need for training public appointees.  This should entail a full understanding of the health care delivery system and stakeholder perspectives. Their stated responsibility must include consideration of all public health care stakeholders equally.

The selection of public appointees needs to be based on pre-established criteria including qualifications and experience.  There also needs to be broader stakeholder representation wherever possible.

Issue #7: The Complaint Process

In today’s environment, there is little motivation for the Colleges to promote or sufficiently resource the complaint process. We are willing to work closely with the colleges to develop a better framework for this.

The complaint process needs to be more effective.  There is a need for formal communication of disciplinary activities from the time of lodging a complaint to final settlement to all third parties.  In the event that there is a suspension of professionals, the payer community is the only sentinel in the health care system.  The business service billings are the primary detection system to determine if suspected professionals are complying.

It may also be appropriate to develop a regulatory model similar to that used for financial services where it is compulsory for payers to submit reports where unethical practices are identified. An effective model would:

• Identify unacceptable practices
• Treating and billing own family
• Unreported conflicts of interest
• Numerous others
• Remove need to use liability releases in the industry
• Allow an alternate dispute resolution process with mandatory reporting.

·         Establish “hold harmless” provisions for the reporter if done in “good faith”.

Note: We recognize that good faith needs to be described and is still contestable if frivolous or vexatious

Colleges must accept complaints from payers (without patient release) in situations where it is necessary to protect the public interest from unethical or potential fraud.  This should be supported by a formal ADR process for payers complaints where there is more than probable doubt about recorded services rendered.

Colleges should be required to order restitution for health care funders where providers are found guilty of professional misconduct in billing for services not rendered, or where practice records falsely support health care service bills issued.  False or improper record keeping in support of services billed is criminal, and should be taken seriously.

Issue #8: Public Health Registry

We would recommend that a central Public Health Registry be maintained (by the MOHLTC) with ownership responsibility for the maintenance of each professional’s status maintained by each College. This would

§            Ensure open and consistent accessibility

§            Establish common standards

§            Deliver efficiency for all major health care system participants

Such a registry would be an important building block for the governance of the evolving electronic health care transaction system – where trusted authentication of ‘business partners’ is required.

Summary

In summary,

• It is important to understand the need for clear governance rules for the professions.

• Colleges need to establish clear leadership in profession ethics, practice requirements and guidelines for accountability between all health care system partners.

• We welcome this opportunity to contribute to the development of this new framework. 

• We believe this work is important and lays the groundwork for the future. 

• We believe that by working together, we can help improve the integrity and financial stability of the health care delivery system.