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Reducing abuse and fraud in health care services for Auto Insurance: everyone has a role to play

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

 

 

What health care practitioners should know:

 

Insurance fraud can impact you in several ways. You could suffer from loss of reputation, be subject to a police investigation and may need to hire legal counsel to clear your name. You could find it difficult to get treatment approved for your clients or receive payment from insurers.

 

The Scenario

 
One way in which fraud may be carried out is when clinic owners/operators and others in the system misuse the signatures and credentials of health care practitioners. They steal a health care practitioner’s name and College registration number and forge signatures. They use this to falsify client records of treatment and assessment plans that were never provided and insurance payments are then forwarded to a phony address.
 

This could also happen where health care practitioners leave a practice and the clinic fraudulently uses their signatures and information after they leave.

 

Warning Signs for Health Care Practitioners

 

  • 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?

What Health Care Practitioners Can Do

 
You can be a gatekeeper to prevent fraudulent health care claims. Exercising your responsibilities appropriately will help reduce potential risks, save money, reduce premiums and protect consumers.

 

If you hear from insurers or law enforcement about possible identity theft, take note of the warnings. By being vigilant and taking steps to safeguard your information, you can build protection and increase efficiencies to reduce identify theft.

 

 

How Health Care Practitioners Can Protect Themselves

 

  • Inform the Regulatory College where you are registered when you move from one clinic/facility to another.
  • Never sign blank treatment and assessment plans.
  • 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.
  • 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.
  • 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.
  • Do not provide a third party with your personal information to process invoices on your behalf.
  • Audit your records on a regular basis to spot inconsistent or suspicious documents.
  • Check HCAI information to ensure it matches your records.
  • Review your billing and payment procedures from time to time to address new risks.
  • Report any suspicious activity immediately.

 

Reporting Suspicious Activity

 

If you have evidence of fraudulent auto insurance claims or identity theft, you can help put an end to the scam or fraud by reporting it.
 
As a first step, report the matter to police. You can also make a report to FSCO’s Fraud Hotline. Go to www.fsco.gov.on.ca/TipNow or call 1-855-5TIP-NOW. Tips to FSCO’s Fraud Hotline can be anonymous.

You can also submit an anonymous tip to Crime Stoppers [New Window] (1-800-222-TIPS).
If you want legal advice, the Law Society of Upper Canada [New Window] has services to help you find a legal professional.

In addition to the police, there are a number of other organizations that you can contact for help.

 

 

For additional information

 

If you would like more information please call the Financial Services Commission of Ontario (FSCO) Contact Centre at: (416) 250-7250, Toll-free: 1-800-668-0128, TTY toll-free: 1-800-387-0584. You can also visit our website at www.fsco.gov.on.ca. For other helpful information, visit: www.ibc.ca — Insurance Bureau of Canada (IBC)​


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