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10 things you can do to protect against insurance fraud

The Financial Services Commission of Ontario (FSCO) has released communication material in an effort to help reduce fraud in health-care services for auto insurance and provides suggestions on what health practitioners can do to protect themselves.

October 28, 2015  By Mari-Len De

“Insurance fraud comes in many forms. With electronic records and easier access to information, health care practitioners are being targeted for identity theft,” the FSCO brochure stated. “Through the illegal use of a practitioner’s name or other identifiable information, fraudsters obtain payment for health care services that were never provided.”

According to the agency, one way fraud occurs is when clinic owners and operators misuse signatures and credentials of a health-care practitioners, such as the practitioner’s name and college registration number. They use them to falsify client records of treatment and assessment plans that were never provided.

This could happen when a practitioners leaves a practice and the clinic fraudulently retains and uses the practitioner’s signature and information for insurance claims.

FSCO offers some fraud warning signs for health-care providers:


• Suspicious documents: Are you seeing treatment and assessment plans, invoices or other records that look altered or forged? Have you seen documents that do not match your own records?

• Suspicious activities: Is a client complaining about receiving a bill for a service he/she never received? Is a client reporting an inconsistency between a treatment and assessment plan and his/her records?

Insurance fraud can have potential repercussions for a chiropractor or other health care provider, including loss of reputation and being subjected to a police investigation, which may necessitate hiring legal counsel. It can also make it difficult for a practitioner to get a treatment approved for patients or receive payment from insurers.

FSCO urges health-care practitioners to be vigilant and exercise their responsibilities appropriately to help reduce the risk of fraud. The agency has some recommendations to help practitioners protect themselves from fraud.

  1. Inform the regulatory college where you are registered when you move from one clinic/facility to another.
  2. Never sign blank treatment and assessment plans.
  3. Explain the treatment and assessment plan to your client. Ensure that your client signs plans only if he/she understands the goods and services being proposed, the costs, and the goals of treatment.
  4. Maintain a record of the services and treatment you provide, as listed on the invoice, to provide you with proof to refute fraudulent claims. You can do this by retaining copies of: treatment and assessment plans for each client; treatment and assessment plans that the insurer has approved; invoices that you submit to the insurer on behalf of a client.
  5. Check that the insurance company notifies the client in writing when they decline all or part of a treatment and assessment plan. The insurer should clearly identify what portions of the plan they will or will not pay for, and the reasons for declining payment.
  6. Do not provide a third party with your personal information to process invoices on your behalf.
  7. Audit your records on a regular basis to spot inconsistent or suspicious documents.
  8. Check Health Claims for Auto Insurance information to ensure it matches your records.
  9. Review your billing and payment procedures from time to time to address new risks.
  10. Report any suspicious activity immediately.

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