10 Shocking Facts About Canada’s Healthcare System – Part 5.

August 14, 2018

Part 5. You May Have Been Unwittingly Been Involved In A Fraud Scheme

Here’s an all-too-common scenario in Canada, based on one story of an actual patient.

This was a 55-year old man who was experiencing problems with his knee. The family doctor referred him to a specialist in a hospital, but when the patient arrived at the hospital some weeks later he discovered that he was scheduled for a series of tests that had nothing to do with his knee. This included a colonoscopy, among other procedures. Alarmed, he told the doctor’s receptionist that he was surprised that this has happened, as he had been expecting his knee to be looked at, and he refused all the tests. At this point the receptionist started whispering that happened all the time at that facility, and that many administrative staff and nurses were upset about all the unnecessary treatments – especially since it was taxpayers that were billed for it. Billing for unnecessary services is fraud.

Apparently, it’s possible for you to be treated by a doctor who isn’t even in the country. ISB Canada has found cases of physicians billing for services supposedly provided at their local treatment facilities while the doctors were actually overseas!

Have you ever been treated by someone other than a physician such as a nurse or a nurse practitioner? Well, there have been cases where patients were treated by such personnel, yet the treatment was billed as having been performed by a doctor because the rate is higher for doctors. There have even been cases where the treating personnel weren’t even qualified to see patients in any capacity. One psychological care facility hired “therapists” who had had no training in the area, and at least one of these bogus “therapists” was hired because he was a friend of the facility’s owner.

Then there was the case of a psychological facility that had a group of unsupervised patients watching a movie that the facility then billed as “group therapy”.

Believe it or not, you don’t even have to be alive to be unwittingly involved in a fraudulent scheme. TVO reports that the Auditor General’s office found $951,900 had been billed and paid out for prescriptions for people who had already passed away. And that was in one year alone (2015-2016).

You may also have received services that you don’t even know about.

In a recent case in Ontario, a doctor falsely submitted claims for a patient’s non-existent conditions. As a result of these imaginary conditions being entered into her medical records, she was unable to get private travel insurance. When she discovered the falsification and asked OHIP to remove the false information from her file, they wouldn’t do it because payments for the procedures had already been made. The patient sued the doctor and one of the doctor’s former employees for fraud.

In one Ontario case, a doctor had labeled many of his patients as having a mental problem and billed the Ontario Health Insurance Plan (OHIP) for these supposed illnesses. The patients knew nothing of this.

Can you imagine going in for a foot problem and getting labeled schizophrenic? Your future is altered and not for the good, and the doctor gets paid by OHIP for it – even though it’s false. Worse still, OHIP might not correct your records!

There are many, many other scenarios you can watch out for. One common example is “unbundling.” In this scheme, a practitioner or a facility takes a bundle of services that are commonly delivered together, and are bundled by the insurance provider at a discounted rate, and bill for the services separately for a higher total rate.

So, just how many ways are there that dishonest practitioners can use to steal money from us? Find out in part 6 of our 10-part series.

10 Shocking Facts About Canada’s Healthcare System – Part 6.

August 8, 2018

Part 6. They Have More Ways To Steal Than You Can Dream Of!

Paul Jesilow, Department of Criminology at the University of California and Bryan Burton, Department of Political Science and Criminal Justice at Southern Utah University specify that:

“Healthcare fraud involves wide-ranging illegal behaviors. It includes such activities as individual physicians who bill insurance companies or the government for services that were never provided, as well as corporate behavior, such as pharmaceutical companies that falsify clinical tests in order to get unsafe drugs approved for use. Thousands die each year in the United States due to these behaviors, including deaths from incorrectly prescribed medications or from tainted drugs that were approved by the U.S. Food and Drug Administration based upon fraudulent testing and reporting. Thousands of additional patients likely are injured and killed by unnecessary surgeries performed by physicians who want to maximize their reimbursements. The illegal activities also add billions of dollars each year to the total healthcare cost in the U.S. Despite these costs, there is relatively little outrage as a result of the behaviors, largely because they remain hidden from public view.”

One of the greatest scams in Canadian history involved Ontario and Alberta paying hundreds of millions of dollars to American hospital chains to treat people for addiction. The hospitals had hired “bounty hunters” who picked up people off the street in Canada to send to these facilities. The “patients” were promised a vacation at taxpayer expense and when they got to the U.S., their “treatment” often consisted of barbeques with hamburgers and hot dogs. They returned in whatever condition they left, and the government paid $150,000 for each of them. And although it was widely exposed in the media, the government did everything in its power to squash the issue. The money was never recovered from the American hospital chain.

In California, there was a case of a hospital that billed Medicare for more than nine years and with more than 150 beds that earned millions of dollars in fees. There was only one problem: the hospital had never been built.

Then there were all the Ontario cases for supposed patients being treated for addiction by Methadone. The patients billed for were street people. Their identities had been procured and were being used to bill taxpayers, but it was nothing but a scam as hundreds, if not thousands, of them did not even reside in the facilities that were doing the scamming. Not to mention that none were ever recorded as cured.

In April 2016 it was exposed in the National Post, headline reading “Methadone doctor accused of coercing patients into using pharmacy linked to his clinic: Patients said the Brantford doctor threatened to cut off their take-home doses and physically walked them into the store, according to a disciplinary ruling.”

Then there are:

Billing for “phantom patients”
Billing for fabricated conditions
Billing for medical goods or services that were not provided
Billing for more hours than there are in a day
Paying or receiving a “kickback” in exchange for a referral for medical goods or services
Concealing ownership in a related company
Using false credentials
Double-billing for healthcare goods or services not provided
Billing for a non-covered service as though it were a covered service
Misrepresenting the provider of the service
Dispensing a lower-cost drug and billing for the higher-cost one
False or unnecessary issuance of prescription drugs
Billing for drugs never dispensed
Unnecessary surgery and other procedures
And several hundred more

How is it even possible that this magnitude of fraud can occur? Is it difficult or even impossible to detect? Emphatically, no. Keep reading – we cover that in part 7 of our series.

10 Shocking Facts About Canada’s Healthcare System – Part 7.

August 3, 2018

Part 7. Fraud Is Simple To Detect, Inexpensive To Find

Every credit card company has ways to detect potential fraudulent activity and they take simple steps to verify the validity of suspect charges. For instance, if they see a charge on a credit card that is atypical such as large purchases made just after small ones (which is, apparently, behaviour characteristic of a criminal with a stolen card) or a large number of online purchases or purchases that don’t fit a cardholder’s profile, they will telephone the cardholder to ask if he or she authorized the purchase. And why? Because credit card companies are intensely interested in stemming the losses they incur from fraudulent transactions.

Banks monitor for fraud all the time, and for the same reason. They use fraud detection indicators to identify anomalies such as unusually high purchases of popular items, they flag multiple accounts opened within a short period of time, they monitor usage patterns. They use readily available software that analyzes data and generates alerts.

Private insurance companies employ a variety of methods, both electronic and good old-fashioned “have a look”, to detect and discourage fraud. They employ pre-payment investigation of flagged claims, they employ forensic accountants, they monitor specific healthcare providers. They have instituted co-pays and deductibles, not just for the cost-saving component but also to give the patient incentive to refuse unnecessary treatment. Some areas of benefit particularly susceptible to fraud and abuse now have annual or even lifetime caps. Some insurance companies limit the quantity of medical accessories that they will cover.

There are software companies, service providers and many other types of business who specialize in providing fraud detection services. And some of them are very, very good at what they do.

When it comes to the government, not only do they have the budget to do this, they also have the means already in hand.

And what does the Ministry of Health and Long-Term Care do to stem the drain of tax dollars stolen by fraud? They’ve set up an email address and a hotline for “the public” to report suspected cases of health card abuse. Please.

How much time or effort would it take the Ministries of Health to do something effective in combating fraud? Take for example the Ontario Health Insurance Plan or OHIP. The Ministry does send letters to patients asking them to verify that they did receive the services that were billed for. This is not a very effective strategy, though, as the response rate from the patients is less than 2%. Instead, how about requiring that a patient sign a form after treatment verifying that the treatment and services being billed for were in fact received? Granted, that would be a nuisance for all concerned but it would make it very difficult for anyone to bill for goods and services not delivered.

Every doctor who bills OHIP has a profile in the system. Well it doesn’t take more than a single report to determine which of these are billing outside of the typical profile. So if you have, say, 1000 of a particular type of specialist in the system billing an average of $400,000 annually, the few that are billing several times that should be easily detected and flagged for investigation. The ophthalmologist who billed $6.6 million in one year springs to mind as do the 154 diagnostic radiologist who each billed OHIP $1 million or more.

Even the Ontario Minister of Health and Long-Term Care recognizes that something is wrong. Eric Hoskins was quoted in the Toronto Star as noting that “2% of doctors … take 10% of the $11.6 billion set aside to pay doctors for their services, offices, staff and equipment”. And what did the Minister propose to do about it? In a classic case of missing the boat, Hoskins wanted to cut fees payable to all doctors. If the Ministry would devote some private-sector-style effort to detecting and deterring fraud, the money that would be saved would not only more than eliminate any need for fee cuts, it would also pay for the fraud detection software, systems, and personnel.

And they can do it. But they don’t.

Are the Ministries restricted in pursuing fraud by the current legal framework? That’s covered in part 8 of our series.

10 Shocking Facts About Canada’s Healthcare System – Part 8.

July 24, 2018

Part 8. Laws And Systems Already In Place To Deal With Fraud

The Criminal Code of Canada is very specific on the subject of fraud:

R.S.C., 1985, c. C-46 says:

Fraud

380 (1) Every one who, by deceit, falsehood or other fraudulent means, whether or not it is a false pretence within the meaning of this Act, defrauds the public or any person, whether ascertained or not, of any property, money or valuable security or any service,

(a) is guilty of an indictable offence and liable to a term of imprisonment not exceeding fourteen years, where the subject-matter of the offence is a testamentary instrument or the value of the subject-matter of the offence exceeds five thousand dollars; or

(b) is guilty

(i) of an indictable offence and is liable to imprisonment for a term not exceeding two years, or

(ii) of an offence punishable on summary conviction,

where the value of the subject matter of the offence does not exceed five thousand dollars.

Minimum punishment

1. When a person is prosecuted on indictment and convicted of one or more offences referred to in subsection (1), the court that imposes the sentence shall impose a minimum punishment of imprisonment for a term of two years if the total value of the subject-matter of the offences exceeds one million dollars.

Affecting public market

(2) Every one who, by deceit, falsehood or other fraudulent means, whether or not it is a false pretence within the meaning of this Act, with intent to defraud, affects the public market price of stocks, shares, merchandise or anything that is offered for sale to the public is guilty of an indictable offence and liable to imprisonment for a term not exceeding fourteen years.

And did you know that there is no statute of limitations for fraud in Canada?

The Canadian Charter of Rights and Freedoms requires that, once charged, the accused must be tried within a reasonable time. In determining what constitutes a “reasonable time,” the clock starts ticking when the original charge has been laid as opposed to when the crime was actually committed. So for indictable offences, there is no specific time limitation on when an accused must be charged. Because of this, those who commit serious offences such as rape, murder, and fraud (if over $5,000) cannot avoid facing criminal charges simply because of the passing of time. That loophole does not exist in Canada.

What does this mean? It means that it’s not too late for the government to backtrack and start hunting down those who have been ripping us off, and hunting them down for real. There’s no such thing as “it happened too long ago”.

And it is within the power of the courts to hand out meaningful sentences to those convicted of healthcare fraud. But do they? Read part 9 of our series to find out.

10 Shocking Facts About Canada’s Healthcare System – Part 9.

July 7, 2018

Part 9. Some Healthcare Fraudsters are Repeat Offenders

Some of those accused of perpetrating healthcare fraud seem to make a habit of it.

In 2000 The Globe and Mail reported that 12 doctors were charged with fraud over $5,000 and with conspiracy to commit fraud. These charges arose from a variety of fraudulent activities including billing for services not rendered and for unnecessary referrals to specialists. The OPP estimated that the fraud amounted to about $2 million just in the year 1997. The doctors charged all worked at a walk-in clinic owned by one of the doctors charged. In 2003 this doctor was committed to stand trial on fraud charges but in 2005 The Ontario Superior Court of Justice granted his application to quash his committal.

Fast-forward sixteen years later, the CBC reported that this same doctor was charged with fraud over $5,000 in a scheme involving unnecessarily referring patients to doctors at a walk-in clinic that he owns (at the same address as the last one, but with a different name). This clinic’s website promises “rapid access to medical specialists”. I’ll bet. CPSO (the College of Physicians and Surgeons of Ontario) lists this doctor as an active member.

In January of 2017, CPSO found that a psychiatrist was guilty of a number of acts of professional misconduct including what the College is pleased to call “inappropriate billing practices” (the rest of us call it fraud) including:

billing for missed appointments
billing for cancelled appointments (including one the doctor cancelled)
billing for telephone calls to patients
billing for telephone prescription renewals
billing for session lengths some of which were more than double the standard
billing ineligible premium codes
double billing for the same block of time

The College did not revoke his license for his “inappropriate billing practices” nor for his failure to “maintain the standard of practice of the profession”, and this despite disciplinary action having been taken against him just three years previously for sexual misconduct with patients. He still maintains his psychiatric practice in Ottawa.

Then there’s the case of the doctor whom CPSO found guilty of various offenses including “inappropriately prescribed high quantities of narcotic medications with too many repeats” as well as not properly monitoring those patients to whom he had prescribed the narcotics. He failed to provide reasons for ordering tests and changing patients’ medications, and he even prescribed drugs to a patient he hadn’t even seen. The College suspended his license for two months and told him he couldn’t prescribe narcotics any more. After the suspension was up, he continued to practice. That was December 2010.

In 2016 they hauled him up before the disciplinary committee again, this time for having pled guilty to criminal charges of defrauding OHIP to the tune of $483,916 (and then fibbing about it on a College form). He resigned his registration with the College. He, at least, is no longer in practice.

But our own personal favourite recidivist fraudster is Dr. Ranjit Kumar Chandra who reputedly fabricated “research” results and then invented another researcher who confirmed Chandra’s results. That’s carrying having imaginary friends a little too far and he was stripped of his Order of Canada appointment in December of 2015. In August 2016, Chandra was charged with fraud over $5,000 in an alleged scheme to defraud OHIP. I’ll say it was over $5,000! The Toronto Sun puts the number at around $2 million. Police say he paid patients to provide their OHIP numbers (and the OHIP numbers of their relatives and friends) and would then bill OHIP for treatments that he seldom or never provided, and often when he was out of the country. CPSO got around to suspending his license in February 2017 by which time he’d already beat a hasty retreat, reportedly to India.

But it is a matter of small wonder that there are those in the healthcare field who view committing fraud as a low-risk proposition when you consider that, even when they are caught and convicted, the penalties meted out to the offenders are so light as to be a bad joke in dubious taste.

Take, for instance, the April 2018 case of two pharmacists in Alberta who pled guilty to taking “secret commissions” of more than $300,000 (and those of us who have no truck with euphemisms call “secret commissions” bribes or kickbacks). They were ordered to pay some restitution and they each got house arrest for six months followed by a curfew. One of the pharmacists continues to work, and the other returned to a farm in Saskatchewan. No jail time.

Another example is a doctor who defrauded OHIP of $597,760 and WSIB of $2.9 million over a four year period. This doctor claimed that the “improper billing” was the result of a failure of due diligence. He pled guilty in the Ontario Court of Justice, paid a fine, and made partial restitution prior to his court hearing. CPSO ordered a three month suspension, a reprimand, an education program, OHIP billing monitoring and costs. No prison time, no revocation of his medical license. He’s currently practicing in Toronto.

Another doctor was found guilty by the Ontario Court of Justice of fraud amounting to $75,000 over a period of four years. He received a conditional sentence, probation and was ordered to make full restitution by the court. The Discipline Committee ordered a 12month suspension, with a six month (but with the suspension period to be cut in half if he ponied up $7,500 to the College within six months). No jail time.

No prison time and no revocation of a criminal doctor’s or pharmacist’s license is not much of a deterrent.

But not all government agencies regard fraud so tolerantly. A woman in BC was recently sentenced to 4-1/2 years in jail for teaching people how to evade taxes. Just last year, a Toronto lawyer was sentenced to 3-1/2 years in jail for defrauding condo investors. A few months ago, a University of Toronto student was sent to jail for 13 months for defrauding CRA. A driver for a vending machine company was convicted of stealing about $20,000 from his employer and was sentenced to four months in jail and was ordered to pay full restitution.

I guess if you want to commit fraud without going to jail, you’d better get some qualifications in the healthcare field.

So what do Canadians think about this situation? Find out in part 10 of our series.