Thursday, May 7, 2015

Recognize health insurance fraud so you can do something about it NOW!!!

Our CHF blog will enable the Canadian public about serious issues of health fraud. In particular, we will address insurance fraud against our Provincial health insurance providers.

In an age where every Canadian is guaranteed health care funded by the public purse, no matter what their station in life, there are still physicians who put their pockets and bank accounts ahead of providing services to their patients.

In particular, we will look at the apparent failure of fiscal oversight that our Provincial watchdogs have demonstrated over the last decade or so. The Ministry fails to provide Access of Information requests to the public in regards to physicians' income, group budgets, and actions taken against any medical group or single physician who has questionable billings.

In fact, as far as I know, there is NO ceiling on physician incomes whether they are in a group or practicing in a solo practice in Ontario. How was this allowed to happen?

Recently the issue of funding FHOs (Family Health Organizations) has surfaced here in Ontario. What was originally set up by the MOHLTC (Ministry of Health and Long Term Care) to provide continuous and guaranteed coverage for patients has instead allowed some of these physicians to walk away with the "bank". 

There have been allegations that the alleged fraud by Medical doctors has been made possible because of sloppy and careless MOHLTC departments that allowed these group practices to grow without control.

The Ontario government, having their purses shrink drastically over the last few years had to do something about this ripoff. In March 2014, the government basically said NO to new FHOs and other group practice structures. That meant that doctors new to Ontario could no longer join these groups. Instead of starting off with a huge guaranteed salary with these groups, new doctors would have to settle for a fee-for-service structure.

The OMA (Ontario Medical Association) has been facing claw-backs of their members' fee structure, and have been unable to help. What the OMA has failed to mention is the fact that the group practice framework in this Province has for the most part failed to provide the 24/7 coverage for the patients.

The opinion of some doctors over the years has been that the groups have been paid way more than they are worth.

When some doctors formed groups, instead of providing full coverage, some doctors basically took a bloody holiday from practice, cut back their working hours, and relied on the Ontario TeleHealth 1-800 call-up service that basically told the callers to go to the local walk-in clinic or ER when there was nobody that was supposed to be on-call for their group. It has been a real mess, and it's just getting worse.

One particular organization basically told the government that they would expand their services by taking over the practices of retiring doctors and agreed to sign their patients up to physicians who they have contracted with to join their FHO. In return, these entrepreneurs were entitled to receive funding up front for these former physicians, whether they were in the office to service the patients or not.

Physicians were given 2,000 or more "rostered" patients to look after. But, in reality they were allowed to filter out those who were perhaps too complex to look after. Did the government know that this would happen? I don't think that they did, nor do I think that they cared.

We will focus on the situation here in Ontario for the most part. But, it is clearly not just here in Ontario. Regulatory Colleges across Canada are also partially responsible for ignoring the issues of health fraud. This brings to mind the awful history of cross-Canada doctor fraud.

A physician who commits health fraud in one Province, seems to be able to just jump from one to another without any College caring a bit.

In a recent Ontario case, a physician was basically forced out of the Province and went to his home across the country. The charges against them were never made public. Why even the database of the CPSO (College of Physicians and Surgeons of Ontario) still has him listed as being active, even though he left the Province many months ago. There is no link to disciplinary actions pending against them here. There is no  transparency here.

But, the web site has registered many complaints against them. Unfortunately, these complaints are anonymous. When asked by members of the public why the CPSO does not have information about why this MD is no longer in the Province, they conveniently duck the issue.

When reliable information about a police investigation into alleged massive health fraud at the offices of an Ontario FHO surfaced a few months ago it really got down and dirty. Allegations of padding the bills, providing services that were never done by MDs, and much more were made by members of the public when they called the Ontario Provincial Police's Fraud Line.

I can't say how many complaints have been made over the years by patients of these physicians to the CPSO. None of these complaints will ever be made public, until these doctors are brought before a disciplinary committee. I also don't know if there have been any lawsuits against any of the physicians.

Suffice it to say, that if just a fraction of the allegations that have been made were even partially true, the physicians involved have a long way to go to try to clear their name.

Then there is the matter of other allegations that are presently being investigated by the police in two Provinces. Because of possible legal action we are unable to discuss this here.

We of course, will try to keep you posted as things develop.

My suggestions to anyone who feels that they may have been involved in any health fraud that involves medical doctors is basically to call their Provincial Fraud Line AND file a complaint with their College of Physicians and Surgeons.

The Canadian Anti-Fraud Centre can be reached on their web site to start the ball rolling if you really suspect health fraud. Your Provincial College of Physicians Surgeons and the respective Colleges of Nurses have limited resources and often rely on this agency to do their investigations.

The Canadian Anti-Fraud Centre can be reached by phone by calling 

But, in my opinion, their web site is really easy to negotiate and you can get your complaint registered anytime. So, go to their web site and let them know you are concerned.

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