health benefits fraud - the beneplan co-operative - presentation to credit union conference 2015
TRANSCRIPT
The Beneplan Co-operative
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Ontario Credit Unions Conference !
Employee Benefits Fraud: Detecting and Managing
March, 2015
• Formed based on customer demand
• 260+ member-owners
• Members are Ontario SMEs w/ 20-400 employees
• Annual growth rate 35%
• 60% blue-collar industries
• The only benefits co-operative in Canada of its kind
About Beneplan
A True Co-operative
Bayview Glen School
Luxury Hotel Group
Audit Committee
• On average, 10% of premiums are refunded as patronage dividends
• 80% of members receive dividends
• Other 20% of members have deficits absorbed by co-op
• $8 million in distributions since 2000
• Source: health, dental, life ins premiums, tax rebates
• Future sources: drug rebates, paramedical rebates
Patronage Dividends
Beneplan.ca All rights reserved Beneplan Inc 2014
!Our industry is the only one where you can give someone $100k and
they are by law not allowed to show you where that money went!
• Tampering with documents in order to file a claim
• Back-dating invoices
• Making deals with practitioners
• Using practitioners’ licences for non-approved services
What is Benefits Fraud?
Beneplan.ca All rights reserved Beneplan Inc 2014
!
It’s a Spectrum
Innocent Abuse Organized Crime
Beneplan.ca All rights reserved Beneplan Inc 2014
!Comes from the employee mentality:
!!
“Who cares about the big bad insurance company. They make so much profit!”
!!
“I am overworked and underpaid!” !!
“It’s covered and its almost Dec 31st so I have to use it up.”
This man is responsible for your escalating benefits premiums.
Beneplan.ca All rights reserved Beneplan Inc 2014
RCMP & OPP say: !!
Every cultural group / ethnicity in the city has an organized crime racquet dedicated to medical/benefits fraud.
!Same gangsters from the 70s are now involved in white collar crime.
PHARMACY FRAUD
Blood glucose test strips submitted so that the patient would be testing
20 times a day. !
What is reasonable is for a diabetic to test 3-5 times per day. Twenty
tests per day translates into10,000 test strips taken in a 1 year period.
!
Sometimes it’s not for them – they might not even have diabetes. It’s
for their family overseas.
!
Fraudulent pharmacies have patterns where they dispense more frequently than needed: 1 package every 2 days instead of 1 package every 1 month.
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Pharmacists would submit claims for test strips or drugs that were
discontinued from manufacturer for the past 2 years
They would submit claims for patients after date of death
!They would completely fabricated claims – fake prescriptions from certificates in their
system !
Continue to submit claims after the MD discontinued the prescription
!They sometimes used to dispense a
generic drug even though it was written “no substitution” on the script for the
brand, just because they’d get a kickback from the manufacturer if they sold a high volume of generic drugs. This has been
made illegal in Ontario as of 2010.
Botox Abuse
NARCOTICS ABUSE
NEW: NARCOTIC MONITORING SYSTEM (NMS)
PARAMEDICAL FRAUD
“What colour were the
compression stockings?”
Acupuncture for Wrinkles
Chiropractic Services
$30
Orthotics / Orthopaedic Shoes: 75% are suspect
Claiming benefits under a child’s name
“Can we please speak to the plan member to ask
what type of service they received?”
Multiple dependents have the exact same
condition !
Same dates !
Same services
DENTAL ABUSE
Social Media being used increasingly by
disability case managers to detect
disability fraud !
Stress leave + posting photos on
Instagram of a trip to Cuba = Red Flag
“How did you get to your
doctor’s appointment?”
Claims Drop by 70% when Pre-approval is introduced
Honour System !
Must fundamentally change mentalities
!
Employees: “Raise your hand if you think your boss loses money
if you don’t use your plan.”
Annual November Benefits Workshop Education, Legal Trends, Knowledge Sharing
A True Community
Thank You !!
Yafa Sakkejha [email protected]
!The Beneplan Co-operative
150 Ferrand Drive Suite 500 Toronto Ontario M3C 3E5
1.800.387.1670 beneplan.ca
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