Canadian HR Reporter

CANADIAN HR REPORTER APRIL 2018 8 NEWS at all kinds of other strategies. That will include civil actions against these people or potentially laying our own criminal charges with our own dedicated prosecu- tors, or engaging Canada Revenue Agency or provider networks… so we're pushing for that, we need that — but it really comes down to a capacity issue." Proactive solutions As a result of the challenges, and costly consequences, plan spon- sors, insurance companies, indus- try associations and law enforce- ment are working on several strat- egies to try and prevent benefits fraud from happening. One of the things Providence Healthcare is working on, with Sun Life, is an approved provider network, said Madigan-Lee. "We'll vet all the firms that we will do business with…. and we will check on these companies on a regular basis to ensure they're viable businesses that we want to actually do business with. It's an extra effort on our part… and I'm sure they'll try to find a way around that, but we'll try to keep ahead of it as much as possible." e basic core of crime preven- tion is creating that risk, so people are less tempted, said Schendera. "If you create that risk, you're going to decrease whatever it is, whatever type of crime it is." As to whether employers should do more when it comes to plan design and policy, it's not necessarily the rules that are the problem, said Madigan-Lee. "The problem is the people who find loops around the rules… I don't want to penalize the people who it would never ever occur to them to misuse a plan because (the benefits are) there for a reason — they're there to keep people healthy and their families healthy. So our point is to get at the risk, the people who are putting us at risk." Education is also needed when it comes to physicians as St. Mi- chael's had physicians who really didn't know they were accomplic- es to the crime, she said. "We've had to go out and do some education with doctors who, in good faith, just thought they'd write a script for somebody." The CLHIA also has a tip line housed on its website, said DeLenardo. "It does allow plan members to either go in and send a tip to one insurer, or they can do it to all insurers at one time through an email," she said, adding even pro- viders that suspect fraud at their clinics can use the tip line. And instead of having each insurer running an education awareness campaign they share with employers and plan mem- bers, the association is hoping to build an industry-wide education campaign, said DeLenardo. "It'll be a situation where it's not for one insurer, it's going to be for the whole industry — everybody can use the information with their own programs, but it's more over- arching," she said. "It's bringing to light some in- teresting information. So we're excited about the direction that it's going to go." e CLHIA is also advocating for greater regulation in the indus- try, said DeLenardo. "We're talking about clinics not being regulated, (so) pushing for regulation in that area, or there's different providers in different provinces, that they're regulated and other provinces are not." Massage therapy is a classic ex- ample, she said, as it's not regulated the same way in all the provinces. "That would be one of the things in terms of a regulation or regulatory standpoint that could help. Colleges… can't stop it alto- gether, but it does put that extra layer on providers." e association is also work- ing with the Canadian Pharmacy Association to create an agreed- upon audit best practices docu- ment, said DeLenardo. "It's frustrating for a pharma- cist or a provider or anyone when you have a multitude of insurance companies looking to do audits, coming in and doing audits at the same time, (in a) different format. It's a burden on their business sometimes. So trying to get an understanding of why the audits are taking place and what they'd be looking for in a communica- tion hopefully will help in that process as well." A Serious Fraud Office set to debut in Ontario will also be a welcome initiative, said Askin. "Although it was initially creat- ed for staged car accidents and the property and casualty business and that type of insurance, it does fit within our mandate as well to get benefits fraud on the forefront. So we're hoping that will assist us." ere are other strategies as well, he said, such as dedicated Crown attorneys or sponsorship of the OPP dedicated to the Seri- ous Fraud Office. "We're open to all the discus- sions — we're open to pretty much anything." BENEFITS FRAUD < pg. 6 Vetted providers, tip line among solutions Shannon DeLenardo of the CLHIA. Credit: John Hryniuk Gary Askin of Sun Life Financial. Credit: John Hryniuk Mary Madigan-Lee of Providence Healthcare. Credit: John Hryniuk Ted Schendera of the Ontario Provincial Police. Credit: John Hryniuk Group benefits fraud occurs when the plan is exploited for the purpose of financial gain. And as fraudsters become more sophisti- cated, so does the need for more sophisticated methods for com- batting it. Big data is fundamental in the fight against fraud. Data mining, reporting and asking the right questions offer extensive capa- bilities in fraud detection — and it starts with predictive analytics. Predictive analytics brings to- gether data science and business analytics in a proactive approach that uses various algorithms to re- view data from claims submitted by plan members, activity from providers, plan member demo- graphics, and much more. e algorithms are based on criteria that look for outliers against normal claiming patterns. e process simultaneously takes a wide range of factors into ac- count to calculate the likelihood of fraud so we can predict where and when new fraud may occur. Sun Life's team of experts has a wide range of backgrounds and experience, including working with service providers like phar- macies and dental offices. It takes raw data and identifies patterns that appear suspicious. The team is able to review alerts and give feedback to the system — a vital component of predictive modelling that allows the system to gather more data and get a better understanding of what is suspicious behaviour. e system grows "smarter" — a form of machine learning. If suspicious activity is confirmed, the formal investigation process begins. Fraud can be committed by a service provider, one or more plan members, or a combination of both. Depending on the fraud scheme, investigators will choose from an inventory of investigative strategies that may include sur- veillance or interviews to gather more information. Many of these cases are com- plex and require many resources, thus a holistic approach is ideal. All stakeholders — group ben- efits provider, plan sponsors, law enforcement, regulatory bodies — should work together to assist in the investigation. e outcomes vary based on the situation. If a service pro- vider is involved, Sun Life delists the provider to stop claims from being reimbursed. If suspicious activity by a plan member is de- tected, Sun Life collaborates with the plan sponsor to demonstrate evidence and work through the recovery process. In some cases, Sun Life may assist the plan spon- sor with interviews, speaking notes, and other ways to help re- duce potential reputational risk. As fraud schemes become more complex, predictive analytics will continue to be a powerful tool in the detection of fraud. Sun Life's team is constantly implementing new techniques including neural networks, linear regression and random forest al- gorithms to analyze vast amounts of data and find the outliers who may be more than just a red flag. To find out more on how to pre- vent group benefits fraud and how to protect yourself, visit www. sunlife.ca/fraudmanagement. Looking into the future of fraud with predictive analytics

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