Insurance fraud is any act committed with the intent to obtain a fraudulent outcome from an insurance process. Insurance fraud occurs when a person or entity makes false insurance claims in order to obtain compensation or benefits to which they are not entitled. Insurance fraud is committed in many forms, but regardless of the type, it is considered a serious crime in all jurisdictions.
In Ontario‚ this type of dishonest criminal act is classified among the most serious of crimes – it’s considered a felony under the criminal act. Those convicted of the insurance fraud face prison time‚ fines‚ legal fees and more – not to mention a wide range of negative personal and professional consequences.
Health insurance fraud is the act of deceiving, misrepresenting information, or concealing information with the intent to receive benefits. Both patients and osteopathic manual practitioners can commit health insurance fraud. Osteopathic manual practitioners can commit health insurance fraud by making false claims, billing for services not provided or supplies not used, or altering existing claims. It is believed that most healthcare providers that commit health insurance fraud do so in order to receive greater compensation that they normally would from extended health plan insurers and other third party payers. This can be done in several ways, including:
• Billing for procedures not actually performed
• Billing for 1-hour of service when less time was spent
• Billing under patient’s family member insurance when the patient has no insurance coverage
• Scheduling unneeded follow-up visits for patients and providing treatments that are not medically necessary
• Providing services for wellness purposes, to prevent injury and disease, to improve quality of life, and to improve athletic performances and billing Ontario extended health plan insurers for these services. Insurers in Ontario do not cover these services. They only cover services that are medically necessary for a current medical condition.
• Offering Yoga, Pilates and other health classes and charging Ontario insurers for these classes as treatments.
• Issuing a paid in full receipt to patients without receiving payments for services rendered. Insurance in Ontario generally reimburse treatment fees when a patient pays in full for services received.
• Offering tow tiered billing, charging cash paying patients less fess than those with extended health plan coverage.
• Accepting only what the extended health plan insurer pays as the full payment and not charging the patient if insurer pays only partial payment. If insurer pays 80% of the treatment cost, patient must pay the 20% remaining balance. The 20% balance in this case cannot be discounted.
If COMPO members become aware of insurance fraud by a patient or a health care provider they must report this criminal act to the appropriate authorities in the jurisdiction the act has been committed.