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Fraud against Great-West is only the tip of the iceberg

by

Alain Thériault

29 August, 2017 13:30

Photo : Freepik

The Press reported last week, a fraud perpetrated to the detriment of Great-West by nearly 80 employees of an office of Shaw Direct in Montreal, who have lodged claims fictitious or exaggerated under the dental benefits of their group plan, between 2011 and 2012. In the light of the answers given in the Journal of the insurance by Great West life, case is not original and the fraud is the subject of special measures in the insurer.

«We have developed and implemented sophisticated features for the prevention and detection of insurance fraud. Among these features, we find the systems controls and the abilities of inquiry «, said by email Jeff Macoun, senior vice-executive chairman, collective client of Great-West. Mr. Macoun remember that fraud can have an impact on the premium that employers and employees pay for their group insurance plans.

The insurer said deploy several efforts to eliminate it. «Our special investigation unit includes former police officers who have received training on investigation techniques and evidence requirements. In some cases, our survey methods also include the use of undercover operations conducted by the investigation firms, private «, he explains.

A phenomenon of great magnitude

Only in North America, the CLHIA estimates that fraud accounts for between 2 % and 10 % of the cost of health care, has revealed Lyne Duhaime, president ofCLHIA Quebec, and senior vice-president of distribution at the national level. «This is huge, considering the amount of complaints,» said Ms. Duhaime, adding that it leads to higher costs for all.

She recalls that the member companies of CLHIA offer supplementary health insurance to 24 million Canadians, and pay more than $ 30 billion dollars (G$) per year for health services provided to the country, either : $ 10.7 billion in prescription drugs; $ 7.8 billion in dental care; $ 3 billion in paramedical and view; $ 1.8 billion in hospital care; and $ 0.8 billion in health care abroad.

According to a study by PricewaterhouseCoopers cited by the CLHIA, the financial sector is part of the sectors where economic crimes are most often reported. The sources of insurance fraud are diverse, » said Ms. Duhaime. «This is why good practices are promoted, in particular in the framework of the activities of the CPOMA. We organize also an annual conference dedicated to the prevention of fraud, where best practices are shared, and we develop tools in collaboration with our partners, » she explains.

Partners include the competition Bureau Canada and the Canadian anti-fraud Centre, in addition to international bodies including theEuropean Healthcare Fraud & Corruption Network, and the Global Health Care Anti-Fraud Network.

Measures to be taken

The signs of fraud on the health care can be subtle and difficult to identify, » said Ms. Duhaime. It calls for the vigilance of all. «The industry recognises that the reduction of fraud and abuse in health care is a team effort. We work in close collaboration with health professionals, clients and law enforcement in order to provide tools and educate in order to limit the cases of fraud «, she argues.

At the last conference on the prevention of fraud, the solution paths have been cited as a good example, revealed Ms. Duhaime. It is, among other things, supervision of care providers non-regulated (for example in the case of the massage), and claims expenses for care in hospitals, transmitted by the institutions, rather than by the patients. It is also necessary to consider with caution the coordination of the data transmitted to the claims in group insurance and those claimed through the health accounts, the X-rays e-to the dentist, and electronic reimbursement of medicines.

Lyne Duhaime also states that the witnesses of insurance fraud can report it from the site of the CLHIA, which then transmits an e-mail to all the leaders of the fight against fraud within the member companies.

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