Skip to content

Patient Guide

Report Medicare Fraud in Canada

Self-Regulation of Medical Profession Does Not Work

Financial Health Fraud is Linked to Patient Harm

Self-regulation is the main distinguishing feature of a profession. The unwritten social contract says:

You have special skills and wisdom. You have unequalled access into the intimacies of people's lives. It is important that the state should not seek to control the development of your professional wisdom or interfere as you deal with the most profound of human difficulties. We therefore trust you to regulate yourselves.

But the Medicare fraud gusher exposed by President Obama in the USA makes it plain: self-governance of the medical profession does not work. The FBI Financial Crimes Report observes: One of the most significant trends observed in recent health fraud cases is the willingness of medical professionals to risk patient harm in their schemes.

  • In several states, the FBI is indicting doctors who perform unnecessary surgeries, prescribe risky drugs without medical necessity, implant medical devices touted by biased research, and engage in other sub-standard care practices.
  • Advances in technology pave the way for new types of electronic health fraud. The FBI is investigating medical database intrusions, illegal online pharmacies, and other scams facilitated via computer.
  • And traditional fraud schemes barrel ahead such as billing for services not rendered, and upcoding for services that are provided.

In the USA, the FBI ensures such fraud gets publicity, and convictions. But Canada does have an equal proportion of health fraud per capita. Only citizens can apply the brake.

How to Report Medicare Fraud in Canada

I Obtain Your Medicare Billing Statement

In the USA where health care is governed by insurance plans, a Statement of Benefits is sent automatically to patients, usually monthly. But in Canada, where universal Medicare is funded through the taxation system, citizens who want to see their own billing data must take the initiative and apply for it. A Canadian guide to obtaining your Statement is available at:

II Report Fraud to the Ministry of Health

When you receive your Medicare billing statement, read it for the educational experience. Fiscal fraud takes many forms. Some is blatant: the doctor may bill twice on the same day for one appointment, or claim for procedures never performed. In a more subtle swindle, the doctor refers to a real event, but pumps up the rate, billing one level higher than the work actually performed (this is called upcoding).

Your doctors should bill for their work in a straightforward way. Health providers should not, under any circumstances, misuse your name or your health number to claim excess fees. Other physicians in your region have access to these records, and if a long-standing pattern emerges without challenge, then you, the patient, may be the one to get saddled with a derogatory profile. This will affect the willingness of other doctors to treat you.

If you find or suspect Medicare fraud, report it promptly to the Ministry of Health in your province. Write a factual letter and send it to the branch that printed your Statement. That branch holds the financial databases required for investigation. For insight into the most prevalent types of health fraud, visit:

III Notify the College of Physicians and Surgeons

If you detect chicanery, you should also notify the College of Physicians and Surgeons in your province. For minor fraud, write a letter of information. For extensive fraud, file a formal complaint. The College regulates these areas: physician licenses; standards of medical practice; complaints and discipline of physician conduct.

The Canada Health Act governs Medicare at the federal level. In addition, each province and territory is permitted to enact a regional Medical Profession Act which reflects local values and politics. The Medical Acts are couched in broad legal terms.

Each province renders its Act into a more practical form – a set of detailed and concrete directives called Medical Bylaws. It is the job of the College of Physicians and Surgeons to enforce these Bylaws. To accommodate the regional disparity in health law, each province has its own independent chapter of the College.

To file a complaint with the College and Physicians and Surgeons, or to learn about the complaints process, visit the website of the College in your province.

Forensic Audit of Medicare in Canada

Dollar

British Columbia has established a Billing Integrity Program to detect, deter and recover inappropriate fee-for-service billings on behalf of the Medical Services Commission. This is one example of how the internet and its surging tide of public reporting has shamed the medical system into trading autocracy for more evenhanded methods.

Have we reached the point of real change? Or is the College of Physicians and Surgeons adept at lip-service and damage-control, telling the public what they want to hear – while behind the scenes we still find incompetence, avarice, and other medical mayhem that gets thoroughly whitewashed?  Time will tell.

The statue of Lady Justice (below) from a court building in the Czech Republic is a good allegory: Systems can move toward democracy, but when the blindfold is abolished from the eyes of Justice, expect resistance.

Lady Justice statue, without blindfold
Allegory: Lady Justice
without scales or blindfold

In B.C. under the new Billing Integrity Program, a forensic auditor will assess physician billings based on seven specific and one general criteria:

  • Was the service medically necessary, and is there evidence the service was actually performed?
  • Is there an adequate medical record or chart entry to document the billed service?
  • Is the service an insured benefit under the Act?
  • Was the correct fee code used?
  • Does the practitioner number on the claim correctly identify the person who performed the service?
  • Are there quality-of-care concerns?
  • Is the frequency of service justified?
  • Are there any other unexplained variations?

The two most frequent billing abnormalities are over-servicing (rendering more services than are clinically required), and mis-billing (substituting fee codes, usually billing for a higher priced item not consistent with the actual service rendered). The Billing Integrity Program employs two main methods to monitor physician billing:

Patient Surveys – Each year, approximately 75,000 survey letters are sent to patients to confirm that they received the services billed on their behalf. These are called Service Verification Audits.

Practitioner Profiles – A profile or spreadsheet is produced annually for each MD in the province, enumerating the type and number of diagnostic procedures, treatments, office visits, and other medical services that he billed for in the previous year. Practitioners are grouped by specialty, and for each group an average is calculated (including standard deviations and medians). Each MD is compared to the average statistics for his group.

Red flags: When a Patient Survey reflects care substantially different from what the MD billed for; when complaints arrive directly from the general public or from other MDs; when questions are referred from licensing bodies or professional associations; or when abnormalities turn up in a Practitioner Profile.

When a physician is investigated, his or her billing statements are reviewed and are either accepted, rejected outright, or adjusted by correcting the fee codes. By the time aberrant billing patterns are recognized, considerable time can elapse.

Therefore an audit is allowed to cover the 5 years prior to the complaint. When the audit is complete, the doctor has an opportunity to review the report and clarify any aspects he can. If the pattern of practice is not justifiable, the Medical Services Commission (MSC) sets out to recover the improperly disbursed public funds. The MSC will:

Recover payments  based on the quantified billing errors extrapolated over the entire audit period, with costs and interest.

Issue a Pattern of Practice Order  which stipulates that the named MD must comply in future with the Payment Schedule.

Modify the billing rights for the MD:  When this happens, the doctor must inform patients before any service is rendered. Two options exist:

Opted-out – The physician must bill the patient directly according to the Payment Schedule and the patient is reimbursed by MSP.

De-enrolled – The physician may bill whatever the market will bear but the patient is not entitled to any reimbursement by MSP.

If the doctor manifests repeated noncompliance or fraud, the MSC may order permanent de-enrollment of billing privileges; may refer the case to law enforcement authorities for criminal charges; or do both.

In all audits that proceed to a hearing, the MSC publishes the physician's name and a summary of the case in the MSP Physicians' Newsletter. The Medical Services Plan (MSP) is the payment arm of the B.C. Ministry of Health. The final step: The College of Physicians and Surgeons of British Columbia is notified.

FURTHER READING

Georgena S. Sil
Saskatoon, Canada
Physicist & Technical Writer
Alumnus: University of British Columbia
TuumEstContact@protonmail.com

Copyright © 2008-2018 Georgena Sil. All Rights Reserved.