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REP 10 - This is real life: undercover investigation video leads to fraud charges

Chantal Lauzon, P.T., Senior Practice Manager, CPA

Our blog today comes in the form of a YouTube video posted by an insurance company to demonstrate a real life example of fraud. Aviva Canada sent its investigators in to a Wellness Centre and a law office. 

Watch it here:

 

Video length 8:55.

What do you think?

  1. Do you have processes in place to prevent fraud? 
  2. Do you regularly audit those processes? Please share what works for you below.

 

 

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Comments

It is sickening to see such corruption. How do these "health care providers" sleep at night?

There is no 100% of preventing this, we need more watch dogs. 10 years ago reported a similar fraudulent clinic, nothing happened, they are still in practice. So I gave up!

I don't know why people are so surprised.   This type of practice has been so widespread and rampant for past 20 years.    Our system has a problem if people are only starting to do something about it.    That's why I have decided to retire from the profession.    I can no longer handle the mental stress with all the unethical stuff that is going on in the industry.    The society has lost a practitioner like me. 

We keep looking st all the things that do and can go wrong - but what about the 98% of us all doing the best we can for the profession and ensuring we are keeping standards up to date and giving appropriate care to our clients without duplication of services.   We need to keep all the "good" clinics in mind 

 

 

First of all, this is chiropractic fraud, not physiotherapy.  The College of Chiropractors is notorious for ignoring complaints and handing out slaps on the wrist for significant breaches of the RHPA.  Our College is MUCH more proactive and serious when complaints come in.

Second of all, for a company like Aviva to make this look like it is happening regularly by providing this video publicly, is quite rich.  Let's just say they aren't above a good sting operation themselves and I have a feeling their practices would be met with some pretty harsh criticism and punishment.

Third, this situation involves lawyers and paralegals who are obviously colluding together.  Given the lawyers are supposed to know the laws, they should be held even MORE accountable than the healthcare team.  All of them should be flipping burgers next month.

First of  all - Did anyone say this was an example of physiotherapy fraud? It is an example of insurance fraud......and insurance fraud is insurance fraud. I can not speak to the College of Chiropractors being notorious for ignoring complaints, but if you think this only happens in chiro oyu are wrong. I personally know of a case with a Physiotherapist and lawyer working together to push clients into a major injury claim bracket. 

 

Second of all - I see no mention of this being a regular event or anything that would suggest that. Your comment about the sting operation almost makes you sound as you are justifying insurance fraud because you dont agree with insurance company practices. 

 

Third of all - I can't even believe you said that? So it is okay for healthcare practitioners to commit fraud because they are not lawyeres and don't know the laws??? WOW! as said above, FRAUD IS FRAUD! If you don't know the law, perhaps you should not be practicing. Or, there is this magicaly thing called the internet where you can find so many valuable resources. I do not practice in Ontario and your system is differnet that what I am used to but when I had a patient who was covered under the Ontario MVA program, I researched the rules online and asked the adjustor anything that I was unclear of. Ignorance is not a defence. Further, these people obviously knew the law very well as they were coaching people on how to get around it, ie, break it. 

 

It all comes down to one thing - ETHICS....and these people obviously do not have any

 

If you personally know of a case, then you are required by law to report it.  I CAN tell you that such a case has not, as of yet, been reported to the College of Physiotherapists of Ontario.  Therefore, rather than try to argue on a blog, it would seem you have a phone call to make to the College of Physiotherapists of Ontario.

At no point did I say fraud was acceptable...what post are YOU reading?  What I said was that the lawyers should be held even MORE responsible and that they ALL should be flipping burgers next week.  Does that sound like I'm supporting anything they are doing?

My MAIN point, which stands, is that insurance companies like to complain publicly about how hard done by they are by fraud, while they continue to demonstrate fraud themselves, sometimes to the tune of patients losing their house or vehicle because they have no money, when they are legitimately entitled.  I know a great many PT's and chiro's who do work for insurers and get patients cut off of legitimate funds by making conclusions that their data doesn't support.  I testify in court to have things like FCE and FAE findings thrown out if they are invalid, and so many times they are.  The point is, that fruad happens on both sides, but the insurers whine and cry about it publicly while many of the patient stories are untold.

Thank you both for sharing your views and joining this important conversation.  This issue almost becomes like a chicken and egg discussion- which came first.  Are people committing fraud to get around the rules of the insurance companies, or are the rules becoming stricter due to the high incidence of fraud.

All we, as individuals, can control at this point are our own behaviours.  By demonstrating to the public, our patients and third party payers that we are committed to ethical business practices, we can help legitimate patients get their claims accepted and access the care they need.

@CPA_Melissa

I agree with your statement about the fraud occurring on both sides. Unfortunately, I do occasionally see patients who are doing questionable things to get more money (and then I have to figure out how to deal with that issue without getting sued myself) - but it is much more common for the insurance companies to make questionable decisions and cause pain and suffering for the patients - all in the name of money.  It seems to me that insurance companies judge all patients as fraudulent based on the actions of a very few.  

Showing this video was only intended to raise awareness that fraud in healthcare does happen in Canada.  

@CPA_Chantal

Thank you for sharing this video.

I worked at a clinic that treated motor vehicle accidents, and my boss - a chiropractor - would regularly question why certain patients were being submitted as only minor vs. major injuries. He would ask me questions such as "Any other symptoms? Headaches? Anxiety? Concussion?" - anything to help convince me, as a new grad physiotherapist, that the patient should be submitted to the insurance company as a major, not minor, injury. I recognized that this prodding was simply to bring in more money to the clinic. This was particularly frustrating since the chiropractor had never met the patients in question. I had to use my ethical backbone regularly, but it still led me to feel increasingly burnt out.

Thank you again for sharing! 

Thank you for sharing your experience.  Our guess is that you are not alone.

 

@CPA_Chantal

OMG! is all I could say. In my current public practice; these situations cannot happen but in the private practice, there's a potential for similar situations that may not be this overt. Ways to avoid these will be showing this video to all staff and ensuring regular unscheduled internal systems audits and self-evaluations. Make staff aware of fraud and conflicts-of-interest in the healthcare system and the potential for it and educate/encourage them to stay honest in all their dealings.

I am sharing this video already- hope no copyright concerns! :)

Thank you for sharing your plans and ideas about prevention.  Awareness is the first step.

Share the video freely- it is publicly available on Youtube.

 

@CPA_Chantal

What makes you think it cannot happen in public practice?  It happens all the time in public practice!  Physicians and PT's assessing patients to make them eligible for catastrophic vs non-cat while still in hospital.  I have seen physicians write incorrect diagnoses so an insurer will cover a private room vs a semi private, to have patients discharged with home care covering house cleaning and meal prep when the patient was capable of it on their own...may not have been for PERSONAL gain, but it was fraudulent nonetheless.

Don't demonize private healthcare clinics-we are just as ethical as public practice.

 

This is not an us vs. them discussion.  Instances of fraud, abuse and waste can occur in all healthcare settings.  This video was a blatent example of fraud, and happened to occur in a private setting.

@CPA_Melissa

The whole thing is disgusting.  I hope there are strong repercussions for those committing such blatant fraud.  The DC should lose his licence .  They should all have to repay what they have stolen.  It was obviously a group effort. I can understand one bad apple but to have 4-5 people in agreement to cheat the system is shameful.  I cannot believe this is common.  I used to be on the other side of this being an independent assessor of MVA victims.  Dealing with dishonest people is draining. The extra money was not worth it so I declined in doing them any more.  There were a few on the up and up but most were trying to cheat the system. To have professionals committing and instigating the fraud just seems so much worse.  They should all lose their jobs.  

There are real consequences for this kind of blatent fraud.  In this case, after the video was turned over to the authorities, charges have been laid against all involved. http://www.newswire.ca/news-releases/aviva-canada-surveillance-video-and-investigation-lead-to-charges-against-toronto-legal-and-health-care-professionals-571893421.html

@CPA_Melissa

I am sooooo angry... this is why I have so much trouble fighting for my legitimate patients to get out of the MIG and into proper care; why the insurance agents are abusing the interpretation of MIG when I submit an OCF-18 AND why we are all paying a FSCO licensing fee (in which sole proprietor's lose out the most because we bring in the least; I don't use assistant's, no other PT's in my clinic , just me). Those people in that video (all of them) should go to jail! 

But I do feel the same as previous commentor, that the insurance company should not publicise it as "broad sweeping fraud" when in fact we know it is a minority and as another commentor pointed out; the insurance system does far worse in costing the system unnecessary expenses (driving insurance costs up) such as IME's. The insurance agents "cherry pick" the professionals I feel they have in their back pocket for upwards of $1500 or more for an IME, for time spent as little as 15 minutes with my patient, to then have the gall to say "my treatment plan is unreasonable and unnecessary" (and my treatment plan is often less or similar to the cost of the IME!). By what standard is it that "that" IME professional's judgement is more valid or correct than mine? When it's just a "no" and the insurance company then accepts and jumps at that as the final word and then uses these same professionals over and over and the patterns are the same "no" (more no's than yes' I would suspect). The system is unfair and is not without prejudice and bias on either side. The government should run the insurance systems (like in Manitoba) as where else can one "write their own bottom lines" because the law states it is mandatory but leaves it to one pravate sector to put in place? The insurance companies still make profits (huge ones) despite the presence of fraud (again how much?). Wherever there are people, there will always be fraud.

As to processes to audit for fraud --- I am only one, so I guess it is easy for me; it's called personal and professional morals and ethics. The difficult thing is to come up with a system that shows I am following all the rules (and that costs me ridiculous amounts of time (and time is money). So it's frustating that by sheer statistics of numbers (populations); the "city slickers" have caused us "country bumpkins" more trouble over the years. 

 

I understand that your intent is to provoke a response, get us thinking and discussing topics like fraud but I am proud to see there was no sign of a registered Physiotherapist in this video. I agree wholeheartedly with the poster above who states Aviva (and many other insurance companies - TD comes immediately to mind) could use a dose of their own medicine. Failing to deal with the insured patients in good faith (ie treating every claimant and their health care provider as a fraudster) is a case more lawyers should take on. I know many ethical and excellent chiropractors who would be appalled at this video but lets not tar our profession with the same brush that has created such distrust between the public and chiropractic. I am an FCAMPT therapist who uses spinal manipulation daily and I see patients every week that tell me they have chosen to see a Physio in private practice as they are scared of chiropractic care causing injury and distrust their business practices. This video supports their opinions and makes me proud to be a Physiotherapist.

We were relieved as well to see that this particular incident did not include a physiotherapist however our profession is not immune. There are stories of fraudulent behaviour affecting almost all health care professions.

@CPA_Chantal

Wow - I am incredibly naive - I had no idea what goes on. Our clinic is so client focussed that I can't even imagine the abuses that have been talked about here and in the earlier reps.  I am mainly an advocate for my patient and his/her care but I also feel i am responsible to their employers, particularly with WCB, and to insurance companies.  We all pay for abuse of insurance. The billing for appointments that the patient doesn't attend must be legal fraud as would be some of the other activities.  Some of the actions seem highly unethical but probably not illegal unfortunately.  I think the control of abuse in a clinic set up like ours would be the front desk who manage and bill.  They would completely know if a payer was billed for appointments that were not real.  Occasionally patients who have missed a WCB appt will say oh just bill for it anyways and I always say i can't - that would be fraud. I have heard that whatever the system is in Ontario that it is much more of a hotbed for fraud----does anyone know if that is true and why? I am in Alberta.

 

 

 

 

You are right- insurance fraud costs everyone.  Insurers have to account for what they lose to fraud. I am please that you are standing up for what is right concerning charging for missed appointments.  While much of the media attention seems to be focused on Ontario, we have heard examples of fraud from coast to coast.

@CPA_Melissa

I am not sure why everyone is so surprised about this.    This type of practice has been ongoing for past 20 years since I graduated.   This is part of reason why I have decided to gradually retire from the profession. I have given enough to the society.   The psychological damage is not worth my life and my family.  

I am surprised not by the fraud, but by people who still want to believe that the world is mostly good.  I don't think it's mostly bad, but definitely getting up there to the 50/50 split.

I don't feel obliged to stop the whole world from spiralling downhill, but rather take on my personal area of influence which I have access to.  My intention in my personal and professional interactions is to influence for the good to the best of my ability.  When I do make a mistake, since I am human, then it is my responsibility to take accountability for my actions.

Isn't that all any of us can do?

 

 

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