CHCAA - Canadian Health Care Anti-fraud Association


	Cost Of Fraud

What is the cost of health care fraud?

Various estimates indicate that from 2 to 10% of every health care dollar in North America is lost to fraud. In Canada, over $120 billion is spent annually on health care. That would mean that cost of health care fraud could surpass $12 billion each year. These figures represent enough money to drastically revitalize Canadian medicare and purchase more than 3000 MRI machines.

However, the cost of health care fraud goes well beyond the numbers.

The perpetrators of some types of fraud schemes deliberately and callously place their trusting patients at serious risk of injury or death. At the same time, an inaccurate health record is created which may impact a patient's future insurability and employability and can be extremely difficult to correct.

What is Fraud?

Fraud is the intentional deception or misrepresentation that an individual or entity makes, knowing that the misrepresentation could result in some unauthorized benefit to the individual or the entity or to some other party. Health care fraud refers to fraud committed against an individual or organization operating within the health care system (see below for examples of health care fraud). Fraud is a criminal offence under section 380 of the Criminal Code of Canada and is punishable by up to 14 years in prison.

Who Commits Health Care Fraud?

Any individual or entity with motive, opportunity, and the necessary knowledge is capable of committing this crime. Therefore, any participant in the health care system can be a perpetrator of health care fraud.

Examples of perpetrators include patients and health care providers as well as staff and administrators within these and other areas. No matter who is committing the crime, it represents a grave cost to the health of all Canadians.

Some Examples of Health Care Fraud

There are many different types of health care fraud. Some of the common examples include:

Services Not Rendered

Billing for services or products that were never rendered or received - either by using genuine patient information to fabricate entire claims or by padding claims with charges for procedures or services that did not take place.

Upcoding

Billing for more expensive services, procedures, or products than were not actually provided or performed. For example, falsely billing for a higher-priced treatment than was actually provided.

Unnecessary Treatment

Performing medically unnecessary services solely for the purpose of generating insurance payments.

Misrepresenting Services

Representing non-covered treatments as medically necessary covered treatments for purposes of obtaining insurance payments.

Unbundling Service

Billing for services separately instead of billing the code that includes multiple services.

Theft/Misrepresentation of Identity

Using another individuals identity, such as their health card, to illicitly receive health care treatment.

Malingering

Exaggerating illness or injury in order to collect financial benefits from health insurance payors.

Doctor Shopping

Receiving various narcotic medications from multiple physicians through acts of deception.

Misrepresenting Eligible Dependants

Maintaining eligibility for or adding an individual who does not legally qualify for benefits under the program.

What can I do?

Health care fraud is a serious issue affecting the health and well being of all Canadians. Although it is a complex problem, there are many things you can do as a member of the public to help protect yourself and your family from fraud. Some of these steps include:

Reading your benefit and billing statements. Read them carefully to ensure that you actually received the treatments that were performed.
Check to ensure that your health care provider has legitimate credentials. Procedures carried out by an unqualified practitioner are dangerous and illegal.
Protect your personal information by keeping your health card in a safe place at all times.
Finally, protect yourself and your loved ones by being a wise consumer. If the services being rendered or the prices seem too good to be true, they probably are.

How do I Report Health Care Fraud?

If you think you have been a victim of or a witness to health care fraud, you are advised to report it to one or more of the following:

Note: Any tips you provide will be treated with the utmost professionalism and confidentiality. However, your anonymity cannot be guaranteed in all cases and will depend on the policies of the organization or entity with whom you choose to file the tip information.