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The Problem of Health Care Fraud |
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The Problem of Health Care Fraud
While estimates vary, it can be safely stated that health care fraud costs Canadians billions of dollars each year. Like other types of fraud, it is a complex problem, as it comes in a variety of forms that can be difficult to detect. What makes health care fraud so pervasive is the fact that it can be perpetrated by virtually any user of the health care system, such as patients, health care providers, staff and administrators, and medical device manufacturers. Whatever the source, health care fraud comes at a high cost to us all.
What Can I Do?
- Ensure that you understand and are in full compliance with the practice guidelines and standards as set out by your profession's regulatory or advisory body.
- Take care to verify that you are properly adhering to payment terms with both public and private insurance payors.
- Double-check claims submissions to ensure that the information is accurate.
How Can I Protect My Practice From Fraud?
There are many steps that you can take as a health care provider to guard against fraud. Be aware of common fraud "red flags" as well as best practices in cost containment and risk management strategies. Reducing the likelihood of fraud within your practice will protect your own professional interests and those of the public. Below is some basic information on the types of fraud you may encounter in the course of practice and a list of some preventative measures that will help to decrease the chances that you will be victimized.
Patient Fraud
- Identity Fraud: This includes impersonation or providing any false personal information (e.g. name, address, etc.).
- Double Doctoring: When a patient attends numerous doctors in order to fraudulently collect multiple prescriptions.
- Prescription Theft: Where a patient steals prescription pads in order to fabricate their own prescriptions.
- Giving False Credit information.
Prevention Strategies
- Receptionist should positively verify identity of new patients by making a copy of their driver's license and/or health card.
- Verify patient's ID at visit by asking "open-ended" questions.
- Keep all prescribing documents in a secure location.
- Insist that you see the patient and ID them if you are not positive about identification.
Office Staff Fraud
- Most commonly involves theft and embezzlement through the manipulation of accounting information and patient records.
- Deleting or altering payments/transactions and patient records.
- Date-altering cheques, ledgers, or patient records.
- Adding fictitious employees to the payroll.
Prevention and Risk Management
- Deploy a computer system in your practice.
- Maintain security controls over payroll and payment transactions (e.g. interac, cash, and cheques).
- Conduct a monthly review of financial transactions and patient records.
- Ensure controlled employee access to sensitive financial and patient information.
- Have all bank statements delivered to your home address.
- Before hiring, carefully check employment history to verify information contained in resumes. When checking references be sure to look up contact numbers yourself.
Cooperation
Health care fraud is a pervasive problem, damaging many different aspects of the health care environment. As such, it must be engaged collaboratively by all stakeholders. It is vital to work together and focus our collective energies on our common goal of protecting the integrity of health care for ourselves and for future generations.