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March is Fraud Prevention Month, which was designed to raise awareness of different types of fraud and provide advice on fraud prevention. There are many types of scams and fraud that might impact RMTs, however the most common type of fraud that RMTs are likely to encounter is benefits fraud. According to the Canadian Life and Health Insurance Association (CLHIA), benefits fraud occurs when you intentionally submit false or misleading information to your insurance provider for the purpose of financial gain.

This article will help RMTs recognize benefits fraud and protect their professional identity

What is Benefits Fraud

Benefits fraud can include but is not limited to:

• Billing for treatments that were never received
• Submitting the same claim to multiple insurers to double the reimbursement you receive
• Letting someone not covered by your plan use your benefits

Fraud is not limited to submitting entirely inaccurate information and can also include deliberately submitting incomplete information. Any finding of fraud can have serious consequences for the RMT or even the clinic where they work. RMTs or even full clinics can be delisted by some insurance companies for indeterminate amounts of time, and RMTs can even lose their license to practice because of fraud.

According to CLHIA, benefits fraud includes:

• Pressuring patients to get treatments or purchase products they don’t need.
• Encouraging patients to claim products or services they did not receive.
• Basing the treatment you provide on the patient’s insurance coverage rather than your assessment of their condition.
• Including false or misleading information on a receipt or encouraging a patient to submit a false or misleading claim.
• Asking patients to sign a blank claims form which could be used later to submit a false or misleading claim.
• Using the patient’s extended health benefits plan to charge for products or services the patient never received.
• Offering cash incentives in exchange for a patient’s policy information.

Of course, benefits fraud is often something a patient chooses to do, and the RMT is not necessarily aware of it. If you are following all CMTO Standards of Practice, especially the Record Keeping standard to ensure you are keeping accurate and thorough records, you are more likely to be able to handle such situations. You can include a consent to disclose personal health information to third parties such as insurance companies as part of your intake process, which will make it easier to share any relevant information with patients’ extended health benefits companies should they be investigating fraud. As long as you focus on being accurate, honest and straightforward, you can avoid issues in these situations.

How to Protect Your Identity to Prevent Fraud

A common concern for RMTs and other health professionals is the possibility that your registration number and/or signature will be fraudulently used by the clinic where you work, or even by your patients. CLHIA identifies steps you could take to attempt to prevent this from happening.

1. Don’t share your registration number until after being hired by a clinic.
2. Ensure the clinic administrative staff, clinic owner and other health professionals who work there have an agreement about the appropriate use of professional information including a protocol for how information will be used after a service is delivered and the invoice/claim is made. To confirm the protocol is being observed in practise, frequently review all invoices/claims made with your license to catch any problems, administrative errors and/or fraud.
3. When you stop working for any clinic, have an agreement that no further invoices/claims will be made with your CMTO registration number and name after your date of departure. Contact the CMTO to change your address of practice.

Sometimes, it is your patients that are engaging in fraud. Although you can’t control the actions of your patients, there are some things you can do to attempt to lessen the impact this may have on you.

• One of the most important things you can do is keep high-quality, detailed records, following all the requirements in the Record Keeping standard and all other CMTO policies and standards.
• Consider issues of consent. You cannot provide personal health information to insurance companies without your patient’s consent. Many RMTs as part of their regular intake process include consent to disclose personal health information to third parties like insurance companies. Oftentimes, insurance companies also have all their clients sign a release form allowing them to access information from health professionals. A copy of such a form would allow an RMT to share information with an insurance company.
• Be as cooperative as possible. Be polite and professional with the insurance companies, and if you are able to provide them the information they are looking for, attempt to provide it in a timely manner. If you are unable to provide the information, you can explain why and see if there’s anything else that can be done.

Conclusion

Benefits fraud can have a negative impact on RMTs especially when it’s perpetrated by a patient or by a clinic that you work with. It can make interactions with insurance companies more stressful, and it may reflect negatively on the RMT with the insurance company, through no fault of their own. Although you can’t control whether or not others attempt to commit fraud, you can control how you conduct your practice and how you respond to potential fraud. Fraud can’t be entirely prevented, but through good record keeping, transparency and professionalism you can attempt to lessen some of the worse potential outcomes.

Tags: fraud prevention