© Copyright 2006 Rogers Publishing Ltd. The following article first appeared in the November 2005 edition of BENEFITS CANADA magazine.
Fact Check: Fuming over fraud
Healthcare’s nasty little secret: fraudulent claims.
By Anna Sharratt

A staggering percentage of employers report they have been the victims of healthcare fraud. Of the 103 Canadian respondents polled from across Canada in December 2004—half of whom were public or private plan sponsors—most have witnessed insurance claim fraud resulting from incorrect billing, up-coding, and billing for performing unnecessary services.

Percentage of respondents who have been victims of fraud with respect to healthcare claims: 94.9%

Percentage of organizations with 3% to 5% of claims containing fraud: 35.9%
Percentage with 6% to 9% of claims containing fraud: 17.9%
Percentage with 20% and higher of claims containing fraud: 11.5%

Percentage of respondents with under five incidents of fraud: 5.1%
Percentage of respondents with over 30 incidents: 48.7%

Top 3 types of fraud:
Billing for services not provided: 89.7%
Up-coding: 67.9%
Billing for more expensive services than were provided: 64.1%

Groups responsible for fraud:
Providers: 87.2%
Individual policyholders: 48.7%

Percentage of respondents who discovered fraud through a claims review process: 76.9%
Percentage who found fraudulent practices through external tips: 68.7%

Percentage of respondents who felt their healthcare fraud control infrastructure was execellent: 5.1%
Percentage who felt it was not very good: 29.5%

Sources: The 2004 Canadian Health Care Fraud Survey.