1. CLHIA Update on Health Benefits Fraud and Abuse
ACFE Edmonton Conference
March 7, 2017

2. Agenda CLHIA/Industry overview CLHIA role in healthcare anti-fraud
Fraud Prevention month
The cost of benefits fraud
The “journey”
Trends
Tips for preventing benefits fraud

3. Overview of CLHIA
The CLHIA is a voluntary association representing 99 percent of Canada's life and health insurance business
Approx 24 m Canadians covered through Extended Health Care (EHC) private plans

4. CLHIA Objectives
To build consensus among members on issues and concerns of importance to the industry.
To promote a legislative and regulatory environment favourable to the business of members.
To foster sound and equitable principles in the conduct of the business of its members.
To inform and educate members about domestic developments and, where warranted, international developments of importance to them.
To preserve and advance the industry's reputation.
To promote, on behalf of its members, public policies that contribute to the betterment of the Canadian economy and society.
To deliver maximum value for money to its members.

5. Health insurance

6. Key stakeholder in healthcare system
Private health insurance accounts for roughly 13% of total health care spending (16% if we include income replacement costs).
ALBERTA 2015 Total Direct Health Care Spending *
Government
(excl. Capex, Public Health, Admin, etc) ($17.6 B)
Hos ($9.4 B)
Physic ($4.6 B)
Drugs ($1.4 B)
Othe ($2.2 B)
Private Supplementary Health ($3.2 B)
HospitAccom ($205 M)
Visio Care ($109 M)
Trav ($153 M)
Para
($342 M)
Dent Care ($1.3 B)
Drugs ($1.1 B)
Income Replace' ($754 M)
STD ($131 M)
LTD
($623 M)
Employers balance all of their benefits to attract and retain employees, as well as to ensure a healthy and productive workforce
Source: CIHI, CLHIA
*Includes Household (out-of-pocket) expenses of $3.2 B 6 6

7. Why do employers offer benefits?
Tax effective form of total compensation
Support employee health to reduce absence/injury and improve productivity
For some employers there are requirements in collective agreements
Driver of employee satisfaction
Attraction and retention of employees 7

8. Group Benefit Plan considerations
Offering benefits is voluntary for employers
Private plans are supplemental to public plans
Rising employee benefit costs are creating concerns regarding the sustainability of plans
Employers seeking more aggressive cost management
Technology is driving change
Fraud and abuse contributes to cost concerns
Medically necessary services or supplies

9. The cost of benefits fraud
Estimated that 2-10% of healthcare $ are lost to fraud
Potential impacts:
higher costs for everyone
may impact sustainability of benefit plans
may create a need for plan design changes

10. CLHIA Role in Healthcare Anti-Fraud
Overall accountability for industry initiatives to assist in mitigating benefits fraud and abuse
Strategic Partnerships:
Global
Law enforcement, public plans, etc
Health/Dental Colleges and Associations
Cross-industry collaboration

11. Tip-line Provides ability to send a tip to a specific insurer
Provides ability to send a tip to all insurers
s are sent directly from senders computer to insurers
“It ain't what you don't know that gets you into trouble. It's what you know for sure that just ain't so.” Mark Twain

12. The “Journey” Information sharing Relationships with stakeholders
Unregulated professions
Industry initiatives
CLHIA Claims and Anti-Fraud Conference

13. Fraud Prevention Month (FPM)

14. FPM: CLHIA Participation
Member of Fraud Prevention Forum (FPF)
Second year for CLHIA participation in FPM events
CLHIA planned activities

15. Sharing the message…

16. Trends Sophistication in schemes- highly organized
Occurs at all levels, ie plan member, plan sponsor, provider, supplier, etc
Cross-industry schemes
Identity theft
Billing for services not rendered
Collusion between plan member and provider
Fake facilities

17. Prevention is key to mitigating benefits fraud
Team effort required
Collaboration with various health profession association and colleges, law enforcement, other industries, etc
Continued education and communication on how all stakeholders can protect themselves

18. Tips for Consumers
Protect your personal information which includes your benefits plan access information
Check your EOB provided by your insurer to ensure it reflects only those services or products obtained by you or your eligible dependents
Don’t sign blank forms
For more information visit Tips for Consumers

19. Final thoughts…
Prevention: Key to mitigating fraud- reject it before it happens
Education: Help plan members recognize how to protect themselves and the benefit plan
Team Effort: We all need to work together to assist in mitigating fraud. If you suspect fraud-report it.
Fraud: