Fraud Protection and Group Health Claims
Group Health Claims Assignment of Payment to Third Party Providers Discontinued
Effective January 1, 2010
Date Originally Posted: 2-Nov-09
Last Updated: 24-Nov-09
To all OJTBF Policyholders with a Group Health plan :
Following an extensive review of their entire block of business1 ClaimSecure has determined that assignment of health claims to third parties (i.e. where payment is made directly to health care practitioners)is responsible for a growing fraud risk. As such, they have recommended the elimination of such assignments. The OJTBF and SSQ concur with this measure. Continuation of assignment is an unacceptable risk to the long term rates of the OJTBF's participating organizations and their employees. Therefore, effective January 1, 2010, assignment of claims to third parties will no longer be accepted for health claims; all payments will be made directly to the insured member (employee) only.
For any claims incurred and assigned on or after January 1, 2010, the payment will be made directly to the insured with the explanation "ASSIGNMENT OF BENEFITS NOT PERMITTED".
This change does not affect Drug, Hospital or Dental claims.
This change does not affect eligible expenses under any plan, it merely eliminates direct payment to third parties--the employee/member and insured dependents will still be reimbursed for all eligible expenses under the terms of the Group Health plan under which they are covered.
The practice of disallowing assignment of health claims to third parties is now a common industry practice according to a survey of the Canadian Health Care Anti-Fraud Association.
Click here for an announcement that can be posted in your office.
If you are a policyholder and have any questions regarding this matter, please contact your OJTBF Account Representative.
Employees/plan members, please contact ClaimSecure at 1-888-777-8811.
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The OJTBF
Your Group Benefits Partner
November 2, 2009
1The study was based on ClaimSecure's entire block of business; the OJTBF is part of that block.
The following outlines some of the identified activities that this process will eliminate:
- Providers will ask the member to sign a blank form for the initial treatments, then submit subsequent claims for services not incurred without the member's knowledge, as the cheques are issued directly to the provider. This is discovered when an audit is sent to the member to confirm treatment was actually provided.
- Providers will bill for items such as compression stockings, braces etc... when the member has not yet received nor ordered such items. Again, this is discovered when an audit is sent to the member asking if they are in receipt of such items.
- Patterns: Providers will sometimes bill to the maximum allowable amount, for all members of the family, on a yearly basis, even though such treatment has not been rendered to the maximum. For example, if a plan covers 4 pairs of compression stockings per year, the providers will submit claims for 4 pairs of compression stockings per year, for every member of the family. This fraudulent pattern also applies to paramedical benefits.
If you are looking at a paper or PDF copy of this bulletin, it can be found at:
www.ojtbf.ca/CLIENT_BULLETINS_2009_No_EHC_Assignment_10-01-htm
