10 Shocking Facts About Canada’s Healthcare System – Part 4.

August 21, 2018

Part 4. When Doctors Are Charged, You Pay Their Legal Bills!

When celebrities like OJ Simpson are accused of a crime they are responsible for paying their legal bills. When mobster Al Capone was arrested in 1931 he had to pay for his legal defense. So did Conrad Black. And Alan Eagleson. This is the case for everyone. Right?

Wrong. If you are a doctor in Canada you enjoy legal protection of the highest caliber, funded by the taxpayers!

In September 2015 the Toronto Star published a scathing indictment of a secretive and largely unknown organization, the Canadian Medical Protective Association (CMPA). Their article was entitled “Suing a doctor? Your tax dollars will be used against you: Canadian physicians are backed by $3.2-billion war chest indirectly funded in part with public money.”

“Following a medical procedure, you find yourself suffering from a serious, unexpected health issue you believe was caused by negligence. You decide to sue your doctor for pain, suffering, loss of income and the costs of care. Here’s what you may not know: you won’t just have to pay your own lawyer. Your tax dollars will finance top-flight lawyers to vigorously defend your doctor and challenge your claims.”

Yes, readers, that’s right. The CMPA is a publicly funded defense organization for doctors accused of wrongdoing. Doctors pay fees to the CMPA and then are reimbursed a hefty percentage from the public coffers, to the tune of hundreds of millions of dollars each and every year. CMPA financial statements show their membership revenue to be $566.2 million for 2016, and that expenditure has been steadily rising well ahead of the general rate of inflation. You paid most of that.

And just to add insult to injury, the egregious defense campaigns employed by the CMPA hired-gun lawyers financed out of their multi-billion dollar war chest are legendary. CMPA lawyers are notorious for their “scorched-earth” tactics of:

deny the doctor did anything wrong
delay, delay, delay
attack the plaintiff
appeal, appeal, appeal

You should also be aware the CMPA does not provide medical malpractice insurance. The CMPA provides high-priced lawyers to doctors. Very few doctors in Canada have actual liability insurance from bona fide insurance providers (they’d have to pay for that themselves). Instead, they rely on the publicly funded CMPA to get them out of any scrape they find themselves in.

And the CMPA’s financing of a doctor’s defense is not limited to medical malpractice issues; they also fund the defense of a doctor accused of civil or criminal offenses. Maimed a patient? Operated on the wrong body part? Slandered someone? Sexually assaulted a patient? Got nailed on a DUI? Committed OHIP fraud? Don’t worry – the CMPA lawyers are all over it. And don’t suppose that the doctor will lose his license to practice if convicted. The Colleges of Physicians and Surgeons, those so-called regulators of MDs and protectors of public safety, are notoriously forgiving of errant, incompetent, and even criminal doctors.

And here’s another disturbing fact: it doesn’t matter how many civil or criminal predicaments a doctor finds himself in – the taxpayer-funded CMPA lawyers will be there for him time after time.

Is it possible that you have been an unwitting and involuntary participant in healthcare fraud? Find out in part 5 of our 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.