Canadian doctors' improper insurance billings near $25M

Canadian doctors were forced to pay back nearly $25 million in improper medical insurance billings from 2010 to 2013, according to data compiled by CBC News.

Health ministries often characterize the recovered money as billing or human errors, but Joel Alleyne of the Canadian Health Care Anti-fraud Association believes that some of the time another term applies — fraud.

"You will see a lot of investigations where somebody audits a claim and says, 'OK, you shouldn't have billed for this,' and the physician will say, 'OK, I'll pay that money back,'" said Alleyne, the association's executive director.

"Sometimes that happens rather quickly, leading one to ask how much was that billing error, or was someone caught with their hands in the cookie jar and deciding to fess up fairly quickly?"

Medical fraud, according to Alleyne, includes billing without seeing patients and billing for a more expensive service than what was performed.

Alleyne's organization is funded by private health insurers and the Ontario Ministry of Health.

7 fraud-related cases reported from 2009-13

Despite the millions of dollars recovered, Canada's provincial health ministries only reported seven cases where doctors were charged with fraud from 2009 to 2013. Six doctors were charged in Ontario and one in Alberta.

In the United States, a single raid in 2010 netted charges for seven doctors.

​"There's a cost in going after someone, either criminally or civilly, and there's a cost to prosecuting them," Alleyne explained.

Authorities don't want to go to the expense or bother of prosecution, he said, noting that provinces are often satisfied when the money is paid back.

Quebec's health ministry says the vast majority of the nearly $8.5 million recovered since 2010 was because of billing mistakes.

Newfoundland and Labrador characterizes the $366,000 it recovered as "fee schedule misinterpretation."

Manitoba Health also shied away from calling the money it recovered the result of fraudulent billing.

An email to CBC News earlier this year said $263,000 of the $747,858 recovered from doctors in Manitoba was the result of fraudulent billing, in the opinion of the province's Health Audit Department.

But last week, the department backtracked, saying the recovered money was "inappropriate billing practices or billing practices not in compliance with The Health Services Insurance Act." It later conceded that it used the term "fraudulent" in the "colloquial sense" of the word.

Often not the doctor's fault, says registrar

The College of Physicians and Surgeons of Manitoba says billing matters are primarily the province's responsibility, but registrar Dr. Bill Pope maintained that improper billing is frequently not the doctor's fault.

"I believe an awful lot of those dollars are, in fact, situations where physicians did not realize that they were using a billing code that may have been higher than was appropriate for what they are doing," he said.

Pope said the CPSM only gets involved when it's alerted to billing misconduct by Manitoba Health, or when it discovers problems during one it its investigations.

The college deals with one or two cases involving inappropriate billing per year, according to Pope.

CBC News discovered three cases of inappropriate billing in just two patient files in an I-Team investigation published this week.

Five cases have been referred to the Winnipeg Police Service by Manitoba Health since 2010, but no charges have been laid against physicians.

Some of the cases involved physicians at Four Rivers Clinic in Winnipeg billing for patients that were seen by a nurse practitioner.

"You have a better chance of getting away with white-collar crime in this country, including health-care fraud, than you would get away with criminal activity with a gun or knife at a convenience store," said Alleyne,

"People shouldn't just be slapped on the wrist for this."

Alleyne said all provinces are now taking the issue seriously, but he added that varying amounts are being spent on detection and prevention of medical fraud.