REP 2 - Fraud, abuse and waste
When thinking about protecting the reputation of the physiotherapy profession, we need to understand three terms and how they relate to our practice. These terms are fraud, abuse and waste.
Fraud is “the crime of using dishonest methods to take something valuable from another person.” (Merriam Webster) Fraud is part of the Criminal Code of Canada. Our provincial regulatory bodies do not define fraud, as the investigation and any subsequent charges are not in the jurisdiction of the registrar, but are the responsibility of the police and justice systems.
When considering how fraud relates to health care benefits, it is, in simplest terms, a crime. It is “the intent to obtain reimbursement for goods or services that were neither received nor provided.” (Manitoba Blue Cross, n.d.)
Fraud related to health benefits can be a single person acting alone, or an entire ring of people working together in an elaborate scheme to profit from the fraudulent reimbursement of health care benefits.
While fraud in physiotherapy in Canada is relatively rare, there are several well-publicized examples that are cause for concern in both the physiotherapy and insurance communities.
There is intent to get money illegally from a payer when insurance fraud is committed. Insurance investigators and auditors are looking for intent, along with prior knowledge and available evidence, when evaluating a tip or complaint. (Humana Inc., 2016)
It seems that health care fraud schemes are limited only by the imagination of the perpetrators. Health insurance fraud can be as simple as providing false information on a receipt, or as complex as a staged car accident resulting in false health benefit claims being made. Unfortunately, Canadian physiotherapists and physiotherapy clinic owners have been involved in several of these examples.
Some examples of health care insurance fraud can be:
Misrepresenting services supplied or the provider of services on receipts
Returning items after reimbursement and not refunding the insurer
Submitting claims for services not rendered
Forging or altering receipts - including patient name, billed amount, service date, etc.
Using another providers’ billing credentials or license
Knowingly providing care to a patient who is using someone else’s insurance card or coverage
Waiving patient co-pays or deductibles and over-billing the insurance carrier
Practicing without a license (Manitoba Blue Cross, n.d.) (Manulife Financial, n.d.) (Cigna, 2016)
Abuse is “a corrupt practice, or improper or excessive use.” (Merriam Webster) We all know of people who may abuse alcohol or drugs (excessive use), or who may abuse their authority (improper behaviour). But how exactly does ‘abuse’ fit with physiotherapists and extended health benefits?
In health care, abuse counts as “practices that are inconsistent with accepted sound fiscal, business, or medical practices, and result in an unnecessary cost or in reimbursement for services that are not medically necessary or that fail to meet professionally recognized standards for health care.” (John Hopkins Medicine, n.d.)
Specifically, insurance abuse is “any action that utilizes the plan in a way that is contrary to the intended purpose of the benefit, which results in unnecessary cost to the plan.” (Manitoba Blue Cross, n.d.)
In physiotherapy, this is most often seen when a patient’s insurance, rather than the patient are treated. This means that if a person has $500 of physiotherapy insurance in their benefits plan, then quite often they require $500 worth of physiotherapy treatment before they are discharged, when in fact they may have improved after only one or two treatments. Abuse is closely related to fraud, but may not include criminal intent. Another difference is that the treatment in abuse cases has often been actually provided to the client, it is simply not necessary.
In addition to the example above, some common sources of health care abuse are:
Misusing codes on a claim
Providing exercises classes, but billing for physiotherapy
Charging excessively for services or supplies
Billing for services that were not medically necessary
Payment for services that fail to meet professionally recognized standards of care (John Hopkins Medicine, n.d.)
Waste is “a situation in which something valuable is not being used or is being used in a way that is not appropriate or effective.” (Merriam Webster, ) Waste is often difficult to ignore in our everyday lives, but may be harder to spot in relation to health care and insurance.
In health care, waste is an “overutilization of services or other practices that, directly or indirectly, result in unnecessary costs to the health care system… It is not generally considered to be caused by criminally negligent actions, but by the misuse of resources.” (Humana Inc., 2016)
Some examples of waste in physiotherapy include:
Providing treatment that has been proven to be ineffective
Prescribing sub-optimal exercise programs- therefore not achieving desired results
Physiotherapists doing tasks that could be performed by Physiotherapist Assistants (e.g. in public practice settings)
Treating patients for inappropriate reasons
Not all of the behaviours described here will lead to stories of criminal charges or in the media. However, if combined, then they could all lead to the deterioration of the physiotherapy professional reputation in Canada.
As social media and word of mouth now eclipse traditional advertising and promotion, it is necessary that we physiotherapists, physiotherapy assistants, physical rehabilitation therapists (in Quebec) and clinic owners work together to protect the good reputation of this profession.
We need to be a truly self-regulating profession, where we hold ourselves and our peers not to a basic standard, but to the high standard that Canadians have come to expect.
We need and want to retain our places as respected members of Canada’s health care system.
What do you think?
1. After reading this, what is your biggest concern about fraud, abuse and waste?
2. What examples of health care insurance fraud worry you the most?
3. How do you mitigate insurance fraud in your practice? Waste?
Written by: Melissa Anderson, PT
Abuse. (n.d.). Retrieved 02 05, 2016, from Merriam-Webster.com: http://www.merriam-webster.com/dictionary/abuse
Cigna. (2016). Report Fraud. Retrieved 02 04, 2016, from Cigna.com: http://www.cigna.com/reportfraud/
Fraud. (n.d.). Retrieved 02 08, 2016, from Merriam-Webster.com: http://www.merriam-webster.com/dictionary/fraud
Humana Inc. (2016). Adressing Fraud, Waste and Abuse. Retrieved 02 08, 2016, from Humana.com: https://www.humana.com/about/legal/disclaimer-and-licensure/fraud-waste-...
John Hopkins Medicine. (n.d.). Health care fraud and abuse. Retrieved 02 04, 2016, from hopkinsmedicine.org: http://www.hopkinsmedicine.org/johns_hopkins_healthcare/providers_physic...
Manitoba Blue Cross. (n.d.). Insurance Fraud and Abuse. Retrieved 02 08, 2016, from mb.bluecross.ca: https://www.mb.bluecross.ca/fraud
Manulife Financial. (n.d.). Fraud and Abuse Prevention. Retrieved 02 08, 2016, from Manulife.ca: https://www.manulife.ca/wps/wcm/connect/76dc2e3b-749f-464f-ac81-e1de86f9...
Waste. (n.d.). Retrieved 02 08, 2016, from Merriam-Webster.com: http://www.merriam-webster.com/dictionary/waste
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