August 2016 Newsletter
fraud
Penny Hill, Chapter Administrator
Kathleen Watson CFE, Newsletter Editor
Coming Tuesday November 15!!!
Health Fraud – Understanding h the Impact and What You Can Do Part II
Volume 11, Issue 7
acfe.toronto@sympatico.ca
by Dorian Dwyer, CFE
CPIO – ACFE CYBERXCHANGE
Case Study – Clinic Fraud Involving Multiple Physicians in the Greater Toronto Area In 2010, the Ministry of Health and Long Term Care (MOHLTC) referred a file to the OPP Health Fraud Unit for investigation. The subject practice was a walk-in clinic which had a significant history with both the MOHLTC and the OPP. The MOHLTC had received a complaint regarding the clinic in 2008 when a complainant called in after being unnecessarily referred to another doctor at the clinic. The MOHLTC received another complaint in 2009 from a former employee reporting similar concerns. That complainant advised she had attended the clinic as a patient for a bug bite and was seen by a gynaecologist. The former employee was interviewed and advised that when she worked there in 2004 she was hired as a “runner” by Dr. X (now charged). Her job entailed swiping the patients OHIP card, taking their complaint, then turning over the file to the office manager who would flag the file indicating what Doctor would see the patient. The former employee or another “runner” would then put that patient in the appropriate examination room. It was not until her visit in July of 2009 that she realized patients were unnecessarily being referred to doctors who could not assist them. This was done to increase OHIP billings.
CYBERCRIME & DIGITAL FORENSICS FORUM & AGM This one-day event will focus on cybercrime, how to protect yourself and your business, and what to do when it happens to you. Expert speakers will help Fraud Examiners and Investigators navigate everything from avoiding both accidental and intentional compromise of your company`s secure systems to looking at a computer forensics criminal or civil case from a defense perspective in order to ensure the best preparation of your case. The Cyberxchange will be held at the BMO Conference Centre, 3550 Pharmacy Ave. Toronto. Breakfast, lunch and afternoon snack will be provided.
The OHIP billings of a number of doctors affiliated with the clinic was analyzed. In 2008, 70 percent of patients seen by a Dr. Y were referred to another provider affiliated with the clinic, and 88 percent of these patients were seen on the same day. It was noted that there were other physicians affiliated with the clinic that had a similar pattern of referring to a select group of physicians. Continued on page 2
Stay tuned for more information!!!
Career Corner If you have a position you would like posted email us at acfe.toronto@sympatico.ca.
Community Partner Update At the ACFE Toronto Chapter, we like to keep up-to-date on what our Community Partners are doing. If any of our members know of anything new taking place with any of our Community Partners please send email us acfe.toronto@sympatico.ca.
Health Fraud – Understanding the Impact and What You Can Do Dr. Y, a paediatrician billed $1,223,930.98 to OHIP in 2008. The billings showed billing code fees for assessments that are designated for paediatric services for all patients regardless of their age, which is unusual given that he is practicing in a walk-in setting and sees patients of all ages, rather than practicing as a paediatrician. By billing the paediatric codes he receives a higher pay than he would if he billed the appropriate assessment codes for general practitioners. During this investigation over three hundred patients were interviewed and undercover operatives were utilized to attend the clinic. A physician previously employed by the clinic was interviewed and provided a statement supporting the allegations. The primary evidence in this investigation was the OHIP billing data. The evidence clearly showed that the clinic’s physicians were up-coding and referring unnecessarily. A search warrant was executed on the clinic in January 2015 and numerous patient files and computer records were seized. At the time of this article, a medical expert is still viewing the patient records. On January 5, 2016 the clinic owner was charged with Fraud Over $5,000. Additional charges against other physicians are pending completion of the medical expert review and forensic accountant report. Previous Related Investigation In 1998 the ARB Health Fraud Unit received a complaint regarding possible fraud (unnecessary referrals) involving the same clinic. Twelve physicians and one employee affiliated with the clinic were charged with Fraud over $5,000 and Conspiracy to Commit Fraud. The court case concluded in 2005 when seven physicians paid restitution for a total of $295,141.82 and three pleaded guilty to Section 44 (1) of the Health Insurance Act and were fined. Criminal charges against the remaining two physicians were withdrawn. The owner of the clinic, pleaded guilty to an offence under section 44(1) of the Health Insurance Act and was fined $1,000.00 and made an additional payment of $1,500,000.00 to the Minister of Finance. The criminal charges against him were withdrawn. He remains the owner of this clinic and the focus of the current investigation. Private (Insurance) Health Care Fraud Private insurance fraud is not a victimless crime just because insurance companies are footing the bill. How do you feel about a cheap (and ineffective) $15 brace charged to insurance at $400 or more? The scams are seemingly endless and the consequences impact the users of private insurance. Examples: • • • • • • •
Beauty spa treatments being billed as registered massage treatment. Erotic massage being billed as registered massage. Organized crime group submitting bogus insurance claims from fraudulent companies and providers. Claims for bogus orthotics and other insured products (Orthotic Ugg boots anyone?). Personal Training for weight loss and body building being billed as Physiotherapy. Employees involved in an organized group benefits scam. Numerous auto insurance scams such as staged collisions
Private insurance Fraud is intrinsically linked to a host of other crimes and sometimes tied to organized crime. Massage parlours and other fraudulent entities may be tied to human trafficking, prostitution and the drug trade. The Consequences: • • •
Increased premiums Decrease in the quality of coverage Inability to continue with service coverage (plan coverage reductions)
Continued on page 3…
Health Fraud – Understanding the Impact and What You Can Do …continued from page 2
By Dorian Dwyer, CFE
So What Can You Do About it? I won’t belabour this point to a professional anti-fraud audience but I will refer to my own organization letterhead footer which states Fraud – Recognize It, Report It, Stop It. I believe this holds especially true to health fraud as most of us give blind trust that our service providers and fellow citizens are honest in their interactions with public and private health care. Having an awareness of health fraud and reporting suspicions will help combat this issue. As per the case study above it was a citizen report to a hotline that triggered the investigation. When receiving personal health care it is up to the consumer to understand what is being billed under their name. When receiving personal health care, it is up to the consumer to understand what is being billed under their name. Consumers can question providers about billings in their name as well as request a personal claims history from the MOHLTC. I would also encourage responding to service verification letters routinely sent out by MOHLTC and private insurers. Deterrence and fraud prevention efforts are difficult to quantify. However, there is evidence that when charges are laid against a pharmacist, physician, vendor of medical devices, or in relation to private insurance fraud and subsequently reported in the media, it can have a deterrent effect on others who might consider engaging in similar conduct. Investigations and the prosecution of health care fraud have played an important role in preserving the integrity and enabling the efficient delivery of health care in Ontario. A Word About Personal Health Information and Protection Act (PHIPA) Updated legislation has just come into effect to increase the penalties and make other changes to this 2004 legislation. The rules and regulations are comprehensive and violators have been recently convicted of offences under this Act. The complaints received by the Privacy Commissioner have been forwarded to the OPP Health Fraud Unit for investigation. http://www.health.gov.on.ca/en/common/legislation/priv_legislation/personal_info.aspx Reporting Suspected Health Fraud Ontario Ministry of Health: To report suspected cases of abuse, the public may call the ministry at: 1 888 781-5556 Reports can be made anonymously or by sending an e-mail to the ministry at: reportohipfraud@moh.gov.on.ca Links for Private Insurance complaints can be found at the Canadian Life and Health Insurance Association (CLHIA): https://www.clhia.ca/domino/html/clhia/CLHIA_LP4W_LND_Webstation.nsf/page/0584182ACA6A87FA85257F1400706E6B!O penDocument Ontario Provincial Police (Public Health Care Fraud): OPP.IB.Anti-Rackets@opp.ca 705-329-6420
About the Author Detective Staff Sergeant Dorian Dwyer has been an Ontario Provincial Police (OPP) officer for 31 years and has been a member of the AntiRackets Branch of the OPP for over 13 years. He is the Unit Commander of the OPP Health Fraud Investigation Unit.
Generation “Y” More Susceptible to Fraud? Recently, Global News On-line reported that an Equifax survey released in March suggested millennials (Generation “Y”) are falling victim to fraud more than any other generation. Because these individuals rely more on technology for their day-to-day activities, they are exposed to more risk. Equifax Canada’s tips for protecting personal data: 1.
Be less ‘social’ within your networks: don’t over share. Tech-savvy thieves can quickly gather what you share on social networks (your home or email address; children’s names; birth date and so on) to use for scams, phishing, and account theft.
2. Fight ‘phishing’ – don’t take the bait: Never give out personal information over the phone, through the mail, or over the Internet unless you have initiated the contact. 3. Check your credit report: Report problems immediately. Check your credit report once or twice per year. Consider signing up for ongoing monitoring of your credit file to safeguard against potentially fraudulent activity. 4. Click with caution: When shopping online, check out a website before entering your credit card number or other personal information. Only enter personal information on secure web pages with “https” in the address bar and a padlock symbol at the bottom of the browser window. 5. Use strong passwords online: Easy passwords open the doors to your personal information. Make passwords more complicated by combining letters, numbers, mixing in special characters and changing them regularly. As well, many banks now offer free notification services to alert consumers when their credit cards or personal accounts have been used/accessed. A text and or email is sent to the consumer with the transaction information. Any erroneous transactions can be immediately identified and reported.
Toronto taxi driver charged with fraud Another taxi driver has been charged for swapping a passenger's debit card and withdrawing money. Read More
Ontario priest charged with stealing $500,000 meant for refugees Police say Amer Saka of the St. Joseph Chaldean Catholic Church allegedly obtained the money from over 20 people under the guise of a sponsorship program to bring refugee families into Canada. Read More
PEI reverend now faces 7 charges after Oshawa widow lost thousands in fraud: Police A reverend from Prince Edward Island is facing additional fraud charges after police allege an elderly widow in Oshawa Ont., was bilked out of thousands of dollars in a home-repair scheme. Read More
'It was all a sham': Director of Surrey real estate company committed fraud, commission finds A Metro Vancouver man who purported to operate a “rentto-own” real estate company that helped people purchase homes actually committed an “egregious form of fraud,” the B.C. Securities Commission has found. Read More
Guelph businesses have been victim of email hacking fraud, police say Investigators say businesses that deal with suppliers overseas have been receiving fraudulent emails asking that payments for services or merchandise be made to new bank accounts. Read More
RCMP, CRA warn variations of taxpayer scam keep victimizing Canadians Pushy scammers impersonate CRA employees and demand either personal information or payment for a made-up fee or back taxes. They will threaten arrest – or worse – if the fee is not paid immediately. Read More
Connect on LinkedIn Did you know the ACFE Toronto Chapter has a new LinkedIn group? Find lots of great connections, articles, discussions, postings. Just go to LinkedIn ACFE Toronto Chapter page by clicking here and ask to be connected to be a part of this lively site.
Your Board of Directors President
William Vasiou, MBA, CPA, CGA, CFE, DAC
Vice President and Training Chair
Astra Williamson, CPA, CGA, CFE
President Emeritus, Secretary and Conference Chair
Tom Eby, MBA, CPA, CA
Treasurer
Erik Bettencourt, CPA, CMA, CFE
Director and Newsletter Chair
Kathleen Watson, CFE
Director and Membership Chair
Ryan Duquette, MsC, CFE, CFCE, CEECS, EnCE, ACE
Director and Social Media Chair
Ryan Watt
Director and Membership and Certification Chair
Linda Lister, CPA, CGA, CMA, CFE, DIFA
Director and Community Outreach Chair
Dorian Dwyer, CFE
Director and Chapter Administrator
Penny Hill
About the ACFE The ACFE is the world's largest anti-fraud organization and premier provider of anti-fraud training and education. Together with more than 70,000 members, the ACFE is reducing business fraud world-wide and inspiring public confidence in the integrity and objectivity within the profession. Visit www.acfe.com for more details.
Upcoming Events: September 11 to 14, 2016 – The Association of Certified Fraud Examiners presents: 2016 ACFE Fraud Conference Canada Venue: Palais Des Congrès de Montreal, 1001 Place Jean-Paul Riopelle, Montreal,Quebec More Information and Registration October 25, 2016 – ACFE – Toronto Chapter presents – Dinner Meeting: “ Where have all the Fraudsters Gone” Speaker: Ross Dunsmore has been advising employers and litigating the termination of bad employees for over 40 years. He is one of the most experienced employer counsel in the country. Venue: Royal Canadian Military Institute (RCMI), 426 University Avenue, Toronto 5:30 – 6:15 pm registration, networking and dinner 6:15 – 7:15 pm presentation and Q&A More Information and Registration
November 15, 2016 ACFE Toronto and CPIO presents – Cyberxchange Watch for more information