Overview of the Problem

According to the Canadian Life and Health Insurance Association (CLHIA), hundreds of millions of health care dollars are lost to fraud in North America every year.^[1]

 Benefits fraud impacts all Extended Health Care (EHC) stakeholders. It increases the cost of premiums paid by employers who sponsor group insurance plans. It jeopardizes the sustainability of coverage levels offered to employees who depend on their group benefits to access the care and drugs they need for themselves and their families.

It also negatively impacts health care professionals who face additional administrative scrutiny and reputational harm because of the actions of a small minority. There is a growing focus on this issue across EHC stakeholders.

 For example, the 2020 Sanofi Canada Health Care Survey reported that fraud is now among the top five concerns of plan sponsors, ranking among other longer-standing concerns such as drug and dental plan sustainability, absence/disability, and the use of Paramedical benefits.

Moreover, a significant majority of both employers (plan sponsors) and employees (plan members) are “willing to get certain products and services, such as orthopedic shoes or massage therapy, from a list of approved providers— and at discounted rates—in order to prevent benefits fraud.”^[2] It is in the best interests of all parties to understand what benefits fraud and abuse looks like, how it can be prevented and what the consequences are.

Recognizing Benefits Fraud

According to the Canadian Life and Health Insurance Association (CLHIA) benefits fraud “occurs when you intentionally submit false or misleading information to your insurance provider for the purpose of financial gain and it can take many forms.

Examples include (but are not limited to):

• Billing for health or dental services that were never received
• Submitting the same claim to multiple insurers to double your reimbursement
• Letting someone not covered by your plan use your benefits.”^[3]

This definition of “misleading” includes submitting incomplete information (e.g. omitting an Incentive and its cost to the patient on a receipt). A finding of fraud or abuse can have serious consequences for health care providers – it can and has resulted in some providers and their clinics being delisted by major insurance providers, for an indefinite period. It can also result in loss of reputation, income or even the loss of your license to practice chiropractic care.

According to CLHIA, all of the following actions constitute benefits fraud:

• Pressuring patients to get unnecessary products or procedures
• Encouraging patients to claim products or services that they didn’t receive, and/or are not covered by their plan
• Providing products or services tailored to the details of the patients’ insurance coverage rather than providing the right product or service
• Including incorrect or misleading information on a receipt or encouraging a patient to include incorrect or misleading information in a claim
• Asking patients to sign a blank claim form (which could be completed later with misleading information)
• Using a patients’ insurance plan membership information to charge for products and services the patient never received
• Offering cash or other incentives in exchange for a patients’ policy information^[4]

Abuse of EHC Benefits

The EHC industry considers benefits abuse to have taken place when employees “use up benefits” whether or not there is a medical or clinically necessary reason. This type of benefits abuse is different than fraud in that it’s not illegal. However, it may contravene the intent of EHC insurance, and jeopardize the sustainability of group plans.

Insurers define medical necessity in the language of plan contracts. For example, they may define eligible services as those which are medically necessary for the treatment of an illness or injury. These contractual definitions are intended to ensure that treatment responds to the patients’ condition or diagnosis, not the specifics of their insurance coverage.

Insurers may request to see your clinical notes and documents if they have questions regarding the relationship between the number or type(s) of visits and conditions or diagnoses being treated. This is among the reasons why it is important to keep accurate and detailed records.

Emerging Pain Research: Nordic Maintenance Care Study

There are instances where the science around what constitutes a recognized illness evolves. As the Canadian Pain Task Force observes, chronic primary pain has only been recognized as a disease in its own right very recently.^[5] In 2018, the World Health Organization announced its intention to include chronic primary pain in the 11^th edition of the International Classification of Diseases (ICD), which comes into effect in January 2022.^[6] Furthermore, there is emerging clinical evidence that maintenance care (MC) can result in “statistically and clinically significantly fewer days with bothersome (activity-limiting)” low back pain (LBP) in specific populations of patients.^[7]

The research on MC is evolving and, in some cases, these developments may not yet be widely recognized in EHC plans. Chiropractors caring for patients who may benefit from MC for LBP should advise their patients to confirm with their insurer whether it is considered eligible before commencing this form of care.

Protect yourself against professional Identity theft

Professional identity theft occurs when your College of Chiropractors of Ontario (CCO) registration number and your signature are used by a clinic or clinician to submit fake claims.

CLHIA identifies four steps that you can take to protect yourself against professional identity theft:

Step 1: Do not give out your license/provider number until after being hired by a clinic.

Step 2: Ensure all your clinic administrative staff, health care professionals and owner(s) have an agreement as to the appropriate use of professional information, including a protocol for how information will be used after a service is delivered and the invoice/claim is made. To confirm the protocol is being observed in practice, frequently review all invoices/claims made with your license to catch any problems, administrative errors and/or fraud.

Step 3: If you are a prescriber, guard your prescription documents.

Step 4: When you stop working for any clinic, have an agreement that no further invoices/claims will be made with your CCO number and name after your date of departure. Contact CCO and advise that you no longer work at the location.^[8]

Preventing Fraud and Abuse, Protecting Sustainability

CLHIA has taken an active role in raising awareness of these issues through an anti-fraud campaign, launched in 2018.

Through its own research efforts, CLHIA determined that many Canadians underestimate the consequences of benefits fraud. Indeed, some 75 per cent of people surveyed believe that the most significant consequences arising from benefits fraud are rising premiums or the obligation to reimburse inaccurate or misleading claims.

The CLHIA anti-fraud campaign seeks to counter these beliefs by highlighting that fraud is “a real crime with real consequences,”^[9] which may include job loss, criminal charges and jail time. The campaign has had a significant impact on public perception of the issues of benefits fraud and abuse. CLHIA reported “more engagement on its anti-fraud websites and more [fraud related] tips coming in.”^[10]

This is one example of the many ways the EHC insurance industry is taking an increasingly collaborative approach to fraud and abuse. Previously, Canada’s life and health insurance providers tended to view fraud detection capacities as a competitive advantage. Today, there is movement within the industry to collaborate on this issue through data sharing. Access to wider and deeper data pools enables the industry to use Artificial Intelligence and Machine learning to more efficiently and reliably detect and resolve patterns that would otherwise be much more difficult.

Spotlight on Incentives

When a product or device is given for free or sold at a reduced price as a complement to a different product or service, this is called an incentive. The CCO does not prohibit chiropractors from offering discounts and incentives to patients, so long as there is no third-party payor involved (e.g. the patient is paying for products and/or services themselves, and does not submit the expense to their EHC plan).

The CCO Guideline on Advertising (G-016) stipulates that:

A member is not permitted to bill any third-party payor or ask for the patient’s health insurance information for complementary diagnostic or treatment services as this practice is unethical and may be professional misconduct.^[11]
Insurance companies prohibit the practice of offering incentives of greater than nominal value because it may result in excessive or unnecessary use of benefits.

With the exception of nominal incentives (e.g. a toothbrush with their dental hygiene appointment, a water bottle with their physiotherapy treatment, or a sample foot lotion with their Orthotics appointment) it is not okay to offer incentives with covered services or supplies. Incorporating the cost of incentives into the cost of covered services or supplies or offering free or ineligible services or supplies to persuade patients to use their coverage when it is not medically necessary, is considered benefits fraud.

For example, some orthotics dispensers have tried offering “free” footwear to patients when they order orthotics. In many cases, the cost of that footwear is recouped by increasing professional fees for patient evaluations. This essentially means that the insurer is bearing the cost of the dispenser’s loss leader.

According to one fraud risk manager, “In the past, we delisted for abuse and fraud and inappropriate business practices. We also now delist for offering incentives, because what we noticed was that facilities are issuing incentives or providing incentives that are beyond a nominal value or not related to the product being dispensed.”^[12]

For more information on insurance best practices, detecting and preventing fraud, check the OCA Webinar: Health Insurance: Your Patients & Chiropractic Services (Presented by CLHIA). We recommend you watch and share this webinar with your administrative staff, as it offers important information for your entire team.