Fighting fraud

Mari-Len De Guzman
December 19, 2016
By
Online filing systems have made the claims process faster and more convenient, but has inadvertently created an environment for fraud.
Online filing systems have made the claims process faster and more convenient, but has inadvertently created an environment for fraud. Photo: Fotolia
When Lisa Blanden got a phone call from the insurance company about a client who was claiming more than $3,000 worth of massage therapy treatments, she checked her records and was flabbergasted. She knew the client was being dishonest.

As a registered massage therapist for more than a decade, Blanden is used to getting calls from insurance companies confirming details – date, length and cost of treatment – on clients filing health insurance claims. That one phone call from the insurance company, however, raised so many red flags.

This particular client was claiming treatments for all five members of the family, worth nearly $3,500 when, in reality, Blanden only treated one family member and the total cost for those treatments was only about $400.

“We found out later that (the client) also did this with other clinics in the amount of about $8,000. That’s quite a discrepancy,” Blanden recalls.

In normal situations, spotting any evidence of fraud will cause people to report to authorities or offer up information to support suspicions of irregularities. It’s not so simple, however, for members of the regulated health profession who may suspect a client or patient is committing fraud. There are federal and provincial privacy laws that prevent health-care practitioners from disclosing personal information about a patient without proper consent. Regulatory colleges governing these health professions – and whose primary mandate is to protect the public – also have regulations that outline the health professionals’ obligations to protect the privacy of their patients or clients.

These privacy safeguards can sometimes be challenging for practitioners, particularly in cases where fraud is suspected – where they want to be transparent with the insurance investigators on the one hand and comply with their privacy obligations on the other.

Blanden faced this dilemma when confronted with that potential insurance fraud. However, in speaking with the insurance company, she learned the company asks all health benefit members to sign a release form allowing the insurer to confirm any claims made by the member. It was just a matter of securing a copy of that signed document and Blanden was ready to provide the information the insurance company needed.

One thing that can save a practitioner a lot of headaches when faced with a potential health insurance fraud is good record-keeping. Blanden is one of several health-care practitioners at Wallis for Wellness, a multidisciplinary health clinic in Brampton, Ont., that’s been around for more than 20 years. Being an established clinic, its record-keeping system is more than adequate.

“We keep excellent records,” Blanden says. “We follow our college’s requirements, so it was fairly easy to obtain the information (for the insurance investigator).”

Transparency is also key. “We’re very forthcoming and supportive of the process,” says Blanden, adding that once the privacy question has been resolved (with the signed client release form from the insurance company) she was able to share the information required by the insurer, and within her regulatory college’s guidelines.

Another case of insurance fraud that Wallis for Wellness recently had to deal with did not go as smoothly, however. The case was fairly similar: a client claiming thousands of dollars worth of massage therapy treatments, when in reality, the actual cost of services provided was only a small fraction of the amount being claimed. This time, however, the client hired a lawyer to prevent the clinic from providing information to the insurance company.

This incident involved another RMT who has since left the clinic (for reasons unrelated to this case), according to Margaret Wallis-Duffy, a registered massage therapist and owner of Wallis for Wellness.

“The minute we get this form from the insurance company asking us to fill this out, lo and behold, we get a fax from the patient’s lawyer saying, ‘cease and desist, do not release any information to the insurance company,’” Wallis-Duffy recalls.

When a client suspected of fraudulent behaviour pushes back and plays the privacy card, it can change the insurance investigation process for the RMT. The threat of a lawsuit can cause a health practitioner to take a step back and reconsider whether he or she would want to move further with the insurance investigation – at least, not without legal representation.

And that’s where the challenge lies. Most RMTs don’t have high-priced lawyers on their speed dial. It’s a potentially costly legal process that most would rather avoid. In this situation, the therapist was concerned and initially declined to send any information to the insurance company.

As clinic owner, Wallis-Duffy worked closely with the investigators to try to resolve the issue without ruffling any legal feathers. She says it was a time-consuming, costly and sometimes frustrating process just to get guidance from authorities in the profession.

“We called the College (of Massage Therapists of Ontario), they said nothing. We called the RMTAO (Registered Massage Therapists’ Association of Ontario), they told us to chat with a lawyer – which costs money,” Wallis-Duffy says. “Who’s got our back? Are we going to pay for a lawyer to defend ourselves when we’ve done nothing wrong? Really?”

The issue was eventually resolved but the lessons learned made a lasting impact.

In a pickle
Most news reports and public knowledge about insurance fraud involve clinics that try to game the system. In some instances, clinics or practitioners are in collusion with clients.

“Benefits fraud can occur at both provider and plan member levels,” says Karen Voin, director of electronic claims and claims fraud issues at the Canadian Life and Health Insurance Association (CLHIA). “For example, signing and submitting claims for services not rendered to their insurer for payment, with payment being shared with the provider.”

The other side of insurance fraud, however – one where the client is the one gaming the system – seldom gets public attention. And practitioners say these types of fraud are inadvertently putting the profession in a bad light.

“It’s impacting us negatively… but it’s not a true picture,” Wallis-Duffy points out. “What ends up happening is that at the end of the year, when employers start to look at their benefits package for employees and they (see) escalating costs for things like massage therapy and preventative health, they’re saying, ‘oh my gosh, this is costing us a lot more money.’ When the true costs have been inflated, significantly in this case, for what it actually was.

“It makes me, as a therapist, look like I’m billing crazy amounts of dollars for something that didn’t actually happen,” she adds.

It can also consequently tarnish the reputation of a clinic or practitioner in the eyes of the insurance companies. But that would depend on how a clinic responds to fraud investigations. It’s one thing for an unscrupulous client to file false claims – that is beyond the control of the therapist. What’s within the RMT’s control is how they deal with the insurance companies in these types of situation.

Wallis-Duffy advises, be forthcoming with any dealings with the insurance companies and ensure that clinic documents are in order – do these things and half the battle is conquered.

If you’re a massage therapist and you’re looking to your regulatory college for help with regard to third-party misuse or abuse of your registration number, it seems there isn’t much the college can do for the profession – other than offer guidelines and recommendations on paper about how to safeguard your registration number.

In an e-mail response to questions from Massage Therapy Canada, Eric Wredenhagen, registrar and CEO of the College of Massage Therapists of British Columbia, explains, “While the issue of insurance fraud by third-party misuse of registration numbers is clearly of great importance to both RMTs and insurers, this issue is not seen by CMTBC as central to its public protection mandate… beyond advising its registrants to guard their registration numbers and to report instances of suspected fraud to the police, there is nothing further the College can do that is within its legal jurisdiction.”

Ontario’s CMTO provided a somewhat similar “public-protection-mandate” response, and listed a number of “information pieces” it has produced to help inform its registrants on safeguarding registration numbers.

These guidelines provide little reassurance for massage therapists – who pay hundreds of dollars in annual fees to their regulatory colleges – when they are actually facing difficulties dealing with third-party fraud and are threatened by legal action.

Blanden finds this worrisome. “Of course, the college’s role is protecting the public. We hope they support us, but their role is to protect the public. They don’t offer any legal support… one of our therapists did call to ask what to do if we are being bullied by a client’s lawyer regarding a false claim, and they said, ‘We can’t really tell you what to do.’

“Short of incurring large legal costs to help protect us, what else is there in place for us? I’m not finding a lot and I’m not hearing a lot,” she says.

Wallis-Duffy would like to see better protection and assistance for the profession from its governing bodies and professional associations. What that would look like, she acknoweldges she doesn’t know, but there needs to be a concerted effort toward a solution where everybody wins and fraud loses.

There needs to be more dialogue among the various stakeholders, she adds.

Ripe for fraud
Up to $30 million a year are lost to health care fraud in North America, according to data from the CLHIA.

Technology advancements, for all its wonders, have also inadvertently created a ripe environment for fraudsters.

In recent years, health insurance benefit claims have become increasingly paperless, allowing members to file their claims online. This convenient process enabled insurance companies to transition to electronic data management and significantly cut wait times for member reimbursement.

Unfortunately, the digital form also created a breeding ground for fraud. Some online claim filing systems would require the member to upload an image of the health services receipt – which typically includes the health professional’s name and unique registration number. Other systems – such as Sunlife’s benefit claims portal – does not require the claimant to upload an image of the receipt, only that the document should be kept for future reference, should the need arises.

“Clearly, there is space for abuse of that system,” comments Andrew Lewarne, executive director of the RMTAO. “There is no way that a practicing massage therapist is going to be able to keep their registration number secret.”

Massage therapy is only regulated in four provinces to date, and in each of these provinces the profession is governed by a regulatory college. These colleges impose guidelines and policies that the profession must abide by to maintain their health professional registration.

One bone of contention is the requirement on RMTs to put their registration numbers on every receipt issued to clients for RMT services. Essentially, somebody who is up to no good can go in for massage therapy treatment, pay for the service and get the receipt – and would now have the therapist’s information, including the all-important registration number, to do with it as they please.

“It’s a very easy process and there’s really not a lot that we can do that we haven’t already done,” Blanden says. “We keep great records and we’re forthcoming. Aside from that, there’s not a whole lot of protection for us as therapists or as a clinic.”

At least one insurance company views the requirement of the registration number on the receipt as “an administrative burden of the claims process.”

Lynn Anderson of Aviva Canada says some incidents of fraud are prevalent in the provider credential area where health practitioners’ college registration numbers are being used unbeknownst to the registered member.

“This should be a concern to every practitioner in the province. The idea that someone could be using your credentials to seek approval for funding, I would think, would be alarming to any professional,” Anderson writes in an e-mail to Massage Therapy Canada.

Here’s where it gets tricky. Many, if not all insurance companies – and certain regulatory colleges – require practitioners to put their registration numbers on their receipts. The CLHIA has published a document, “Service and Supply Provider Receipt Best Practices for Group Benefit Reimbursement,” in which it indicates the “provider professional identification” number assigned by a regulatory body as one of the items that should appear on all receipts for health benefit claims purposes.

The CMTO also requires its registrants to put their number on their receipts. The college’s website states: “The date of the financial transaction, the description of the service, duration of treatment and the name of the payer must appear on the receipt. Receipts issued for Massage Therapy treatment also require that the name of the therapist is printed or stamped on the receipt along with the Massage Therapist’s registration number and signature.”

The CMTBC, however, does not require its members to put their registration number on RMT receipts, according to its registrar and CEO Wredenhagen.

“If that requirement does in fact exist, it is presumably a requirement imposed by the insurance companies themselves,” Wredenhagen says.

It’s a total catch 22 and RMTs are at the receiving end of it.



Mitigation
Despite the ongoing challenges to finally rid the world of health insurance fraud, it appears there is no way to completely eradicate it.

The good news is there are a few things that the industry can do to protect against fraud or at the very least, keep the RMTs’ professional reputation intact.

The easiest safeguard to implement would be during the patient intake process, RMTAO’s Lewarne suggests. Obtain a signed release form from the patient, which essentially gives the therapist permission to respond to any request for information by the client’s extended health insurance provider for purposes of claims reimbursement.

CMTO’s guidelines under its “Release of Records” policy indicate the signed release form must be dated within the last six months.

Lewarne also says communication is key to fraud prevention. “What needs to happen is there needs to be very clear communication and very clear desire to help each other, from both the insurers’ point of view and the health professionals’ point of view.”

When the insurance company calls to confirm a certain transaction to satisfy a claim submission, the health practitioner involved then has to first satisfy his or her privacy obligations and notify the patient of the insurer’s inquiry. In most cases, patients will give consent, which then allows for a smooth transactional flow with the insurer. When a patient refuses and prevents the practitioner from sharing the information with the insurance company, then the insurance company may refuse to pay the member’s claim for reimbursement.

Through all this process, maintaining an open dialogue between the parties involved – the health practitioners, the client, the insurance adjustor or representative – is key, Lewarne says.

“The more that we try to make things easy, the more in-depth and the more complete the communication has to be. Sometimes, people forget that that is an intrinsic part of the equation – that communication,” he adds.

Lewarne would also like to see an earlier pilot project designed to help prevent fraud expanded to the larger health profession. In 2014, the Financial Services Commission of Ontario implemented a pilot project called the Professional Credential Tracking program, which enabled health professionals to track through the system where their registration numbers are being used, when and who’s using them.

The system empowers the health practitioners to be more proactive in protecting their registration number – and their reputation – and determine whether their identity is being used in fraudulent activities and report them right away.

“At that point, you actually have a partnership between the insurance industry, the regulatory colleges and the health professionals,” Lewarne says. Unfortunately, he adds, the project was limited to the Health Claims for Auto Insurance only.

“I kind of hoped it would expand to the extended health care benefit world, because I think it would be terribly useful to allow for the various health professionals to assist in the identification of fraud,” he adds.

Based on responses to this publication’s inquiries, it seems some level of communication among the stakeholders is already happening. According to the CMTO it works with insurers, law enforcement, registrants and other stakeholders to educate and inform about health care fraud, “in order to protect the public.”

Insurance companies also continue to collaborate with the various professions as well, according to CLHIA’s Karen Voin. For example, the organization and its members participate in an annual Fraud Prevention Month activity. Published documents, such as the “service provider receipts best practices” and “understanding claims for footwear and orthotics,” are designed to educate the public and providers to minimize the impact of fraud.

“The industry recognizes that reducing health care fraud is a team effort,” Voin tells Massage Therapy Canada in an e-mail, “and the best way to mitigate the fraud and abuse is to work with stakeholders to prevent it from occurring.”

The insurance industry also participates in health profession consultations, where appropriate, such as the recent Ontario Clinic Regulation Consultation – which is another way the health profession is trying to mitigate fraud and abuse, Voin adds.

The CLHIA executive emphasizes there is only a small number of any profession that is involved in health benefits fraud and abuse, and points out that fraud is not unique to only one profession.

The consequence, however, can be significant.

Voin explains that benefit plans are purchased by employers, and each insurer invests significant amounts of money and resources to prevent, identify and stop fraudulent activity. This has required more “evolution and investment in fraud management” by the industry.

“Sustainability of plans has become an increasing concern for employers over the last several years due to increasing cost pressures (high-cost drugs, etc.),” Voin says. “Fraud and abuse of benefit plans add to these cost pressures which, over time, may create a need for changes which would have an impact on everyone covered by that plan.”

For example, she adds, employers may need to make difficult decisions to reduce benefits, implement co-payments or deductibles to share the cost burden with their plan members.

There may not be a one-size-fits-all solution to health care fraud. It is clear all stakeholders recognize that fraud exists and it hurts everyone.

“There’s the idea that everyone is trying to get away with something – and that’s not true,” RMTAO’s Lewarne says. “Everyone is trying to perform to the best of their professional ethics and we need to communicate that to each other and I don’t think it’s difficult.”

If there’s one thing that fraud does not like, he adds, it’s transparency.

Health insurance fraud by the numbers
  • CLHIA member companies provide supplementary coverage to 24 million Canadians
  • More than $30 billion is paid annually through extended health insurance benefits delivered to Canadians
  • Between two and 10 per cent of all health care dollars are lost to fraud

Source: Canadian Life and Health Insurance Association


Mari-Len de Guzman is the editor of Massage Therapy Canada. She has worked in publishing for more than 20 years. You may contact her at This e-mail address is being protected from spambots. You need JavaScript enabled to view it .



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