Report Medicare Fraud in Canada

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How to Report Medicare Fraud in Canada

I    Obtain Your Medicare Billing Statement

In the United States where health care is governed by insurance plans, a medical billing statement 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. For instructions on how to obtain your billing statement, visit:

Obtain Your Medicare Invoice (Canada)

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 MD may bill twice on the same day for one appointment, or claim for procedures not performed at all. In a more subtle swindle, the MD refers to a real event, but pumps up the rate, billing one level higher than the work actually performed. Also be alert for unusual patterns on the statement, such as when a wrong address suddenly appears for a clinic or provider: this is a red flag for diversion of funds.

Your doctors should bill for their work in a straightforward way. Doctors and other providers should not, under any circumstances, misuse your name or your Health Card Number to claim excess fees. Other MDs are aware of these records, and if a long-standing pattern emerges without challenge, then you the patient may be the one who gets saddled with a derogatory profile. This will affect the willingness of other MDs 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 specific Health branch which printed your statement. That branch holds the financial databases required for investigation.

III   Notify the College of Physicians and Surgeons

If you detect fiscal 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 is the governing body for all physicians in Canada. The College regulates these areas:

•  physician licenses

•  standards of medical practice

•  investigation of complaints against doctors

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 reflective of local values and politics. Said Medical Acts are couched in broad legal terms. For practical use, each province renders its Act into a set of specific, 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, there is a separate chapter of the College in each province and territory. The location of each College office is listed at:  Provincial Offices:  College of Physicians and Surgeons

To file a complaint with the College and Physicians and Surgeons, or to learn about the complaints process, visit the link below which matches your province:

-  College of Physicians and Surgeons of British Columbia  Complaints and Concerns

-  College of Physicians and Surgeons of Alberta  File a Complaint

-  College of Physicians and Surgeons of Saskatchewan  Complaints

-  College of Physicians and Surgeons of Manitoba  Complaints and Investigation

-  College of Physicians and Surgeons of Ontario  Complaints

-  Collège des Médecins du Québec  Complaints

-  College of Physicians and Surgeons of New Brunswick  The Complaints Process

-  College of Physicians and Surgeons of Nova Scotia  Complaints and Investigation Process

-  College of Physicians and Surgeons of Prince Edward Island  The Complaint Process

-  College of Physicians and Surgeons of Newfoundland and Labrador  Complaints and Discipline

-  Yukon Medical Council Complaint Process

-  Government of the Northwest Territories  Health Care Service Complaints

-  Government of Nunavut  Health and Social Services


Hippocratic Oath  –  Modern

The Hippocratic Oath was written almost 2500 years ago, yet the spirit of the Oath remains as relevant as ever. The one exception is the feature of paternalism, for the original Oath was doctor-centered and silent about patient rights. During the 20th century, the Hippocratic Oath underwent several revisions to include the moral codes of patient autonomy, informed consent, and shared decision-making. At the start of the 21st century, updates to the Oath continue, focused on physician accountability and severing MDs from conflicts of interest.

A Guide to the Hippocratic Oath

BBC News (26 Oct 2008)

The Doctor Patient Relationship:
Biomedical Ethics

North Virginia Community College

A Catalog of Physician Oaths

Dr. Charles Yanofsky

Swearing to Care: The Resurgence
in Medical Oaths

British Medical Journal (1997)

Earliest surviving
papyrus fragment of
the Hippocratic Oath

Source: A disciple
of Hippocrates

Date: Circa 275 AD

Language: Greek

Site of excavation:
Oxyrhyncus, Egypt

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 shows that self-regulation of the medical profession does not work. The 2008 FBI Financial Crimes Report says: 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. The FBI in several states are indicting doctors who conduct unnecessary surgeries, prescribe dangerous drugs without medical necessity, and engage in abusive or sub-standard care practices. Advances in technology also pave the way for electronic health fraud. The FBI is investigating medical data theft, illegal online pharmacies, and other scams facilitated via computer. And traditional fraud schemes continue such as billing for services not rendered, and up coding for services that are provided.”

Canada and the USA have an equal proportion of health fraud per capita.

Hippocrates

(460 - 377 BC)

Statue stands in the main court of the
University Museum of Natural History
located in Oxford, England

Hippocratic Oath

Greece ~ 400 BC

“I will use regimens for the benefit of the ill in accordance with my ability and my judgment, but from what is to their harm and injustice I will keep them.”


Hippocratic Oath  –  Classic

Hippocratic Oath  (400 B.C.)

Translation from the Greek by
Heinrich Von Staden

Hippocratic Oath  (400 B.C.)

Translation from the Greek by
Ludwig Edelstein

Excavation of Hippocratic Papyri

British Medical Journal 1964

Hippocrates Collected Works

Cambridge Harvard University Press

Corpus Hippocraticum

Translation from the Greek by
Francis Adams

On Airs, Waters, and Places

On Ancient Medicine

Disease Prognosis

The Law

Aphorisms

Forensic Audit of Medicare in Canada

BC Ministry of Health: Billing Integrity Program

BCMJ Special Report:  Billing Integrity Program

In 2008 British Columbia 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 becoming adept at lip service and damage control, telling the public what they want to hear while behind the scenes incompetence, avarice, and other medical mayhem 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.

In British Columbia, under the new Billing Integrity Program, a forensic auditor will assess physician billings based on seven standard criteria:

•  Was the service medically necessary, and is there evidence that the service was actually performed?

•  Is there an adequate medical record documenting the service billed?

•  Is the service an insured benefit under the Act?

•  Was the correct fee code used?

•  Does the practitioner number submitted on the claim correctly identify the person who performed the service?

•  Are there quality-of-care concerns?

•  Is the frequency of service justified?

The sampled claims are reviewed and are either accepted, adjusted to the value of the correct fee code, or rejected. By the time aberrant billing patterns are uncovered and investigated, considerable time can elapse. An audit therefore covers a period of 5 years. 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 physician must inform patients of all details before any service is rendered. Two options exist:

  1. Opted-out: The physician must bill the patient directly according to the

  2. Payment Schedule and the patient is reimbursed by MSP.

  3. De-enrolled:  The physician may bill whatever the market will bear but

  4. the patient is not entitled to any reimbursement by MSP.

If the doctor manifests repeated noncompliance or fraud, the MSC may order permanent de­enrolment of billing privileges; refer the case to law enforcement authorities for criminal charges; or 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.  As well, the College is notified. The Medical Services Plan (MSP) is the payment arm of the B.C. Ministry of Health.

 


Dr. Arun Nayar

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Dr. Larry Hardy

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Pleasant Hill Plaza Medical Clinic

•  Investigation

•  Verdict

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Obtain Your Medicare Invoice

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Report Medicare Fraud (Canada)

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Larceny and the Stethoscope

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