Healthcare Fraud in Canada

PART 1 OF THE WHITEPAPER SERIES

healthcare
fraud in canada
why is it not a hot topic?

Our healthcare system is haemorrhaging $37.5 million per day

and nothing is being done about it
Why is healthcare fraud
not a hot topic in canada?
Canadians are known as a polite people. Perhaps too polite when it comes to
discussing or investigating the topic of fraud in this countrys healthcare system.
It probably seems discourteous to most, if not downright rude, to impugn the
character of healthcare organizations and providers which are entrusted to
handle their most important commoditytheir health.
We tend to believe that these paragons of caring and healing are above ripping off
the very system which supports them. Looking over the press in recent years, our
governments must certainly think this way.
Healthcare funding is the most talked about topic by government leaders in this
countrytalks between the federal government and the provinces over funding
have been a major story for months. Yet, we rarely hear anything about curtailing
potential fraud within the system.
Is Canada really a fraud-free

paradise in health care?
Lets look at the American experience for a moment.
The U.S. operates a socialized healthcare system for the indigent, elderly, military,
disabled and children/youth with their Medicaid, Medicare and Tricare systems.
Medicare and Medicaid are two different government-run

programs that were created in 1965 in response to the inability of
older and low-income Americans to buy private health insurance.
Medicare is a federal program that provides health coverage if you

are 65 or older or have a severe disability, no matter your income.
2017 MONITOR TELEGRAM | All Rights Reserved | PAGE 2

Medicaid is a state and federal program that provides health
coverage if you have a very low income.1
Tricare, formerly known as the Civilian Health and Medical

Program of the Uniformed Services (CHAMPUS), is a health care
program of the United States Department of Defense Military
Health System.
The U.S. spent $540 billion US on Medicare in 2015 on some 57 million people2
and another $532 billion US on Medicaid.3 In comparison, per the Canadian
Institute for Health Information, Canada spent $228 billion in 2016.4 Thats more
than $26 million each hour of every day, around the clock.
The Centers for Medicaid and Medicare, the U.S. federal agency supervising the
programs, is very concerned about criminal fraud. On the following page are
some of the common schemes theyve identified that take advantage of Medicaid.5
(For a more detailed explanation of fraud schemes and the U.S. system to deal
with them, download a PDF file here.)
1 https://www.medicareinteractive.org/get-answers/introduction-to-medicare/explaining-medicare/
what-is-the- difference-between-medicare-and-medicaid
2 http://kff.org/medicare/issue-brief/the-facts-on-medicare-spending-and-financing/
3 http://kff.org/medicaid/state-indicator/total-medicaid-spending/?currentTimeframe=0
4 https://www.cihi.ca/en/spending-and-health-workforce/spending
5 https://www.cms.gov/Medicare-Medicaid-Coordination/Fraud- Prevention/FraudAbuseforConsumers/
Ripoffs_and_Tips.html

Common Rip-Offs
Payments (in cash or in kind) in return for Medicaid numbers,

Every patient in a group setting receiving the same type of
service or equipment on the same day, and
Services listed on your medical summary notice that you dont
remember receiving or didnt need.
Common Fraud Schemes
Billing for phantom patients,

Billing for medical goods or services that were not provided,
Billing for more hours than there are in a day,
Paying a kickback in exchange for a referral for medical goods
or services,
Concealing ownership in a related company,
Using false credentials, and
Double-billing for healthcare goods or services not provided.

The unsupportable cost
of health fraud
The Federal Bureau of Investigation (FBI) says that health fraud costs U.S.
taxpayers tens of billions of dollars a year.6 This includes fraud in both
government-funded and private insurance programs.
We cannot find a comparable statistic in relation to Canada. However, the CHLIA

(Canadian Life and Health Insurance Association), reports that All Canadians pay
for healthcare fraud. In North America alone, it is estimated that 2 to 10 per cent
of all healthcare dollars are lost to fraud [an average of 6 per cent]. This means
higher costs for everyone.7
So how much is bleeding from the

Canadian healthcare system?
We are losing healthcare funds at an incredible rate:
$13.7 billion per year8

$37.5 million each and every day, or
$1.6 million per hour, 24 hours around the clock
There is widespread concern in the U.S. over healthcare fraud. There is major
media almost daily on some company or provider being arrested, charged or
convicted of such crimes.
Why not in Canada, considering the figures above?
6 https://www.fbi.gov/investigate/white-collar-crime/health-care-fraud
7 https://www.clhia.ca/antifraud
8 Average of 6%7 of $228 billion4 spent in Canada

Canadas public double speak
Part of the problem appears to be rather than calling it what it is, criminal
healthcare fraud, governments and media here like to use polite terms like over-
utilization, over-billing and other benign, nonjudgmental administrative words.
A Toronto Star story from December 30,

Services not rendered
20169, is a case in point. The Star has been
hammering at the Ontario government to
Upcoded
release a list of the provinces top billing Medically unnecessary
doctors, some of whom have billed millions Inappropriately delegated
of dollars for their services.
...Seeing over 100,000
The paper obtained documents relating to patients in 332 days!
findings from an Ontario health ministry
investigation into the top 12 billing doctors in the province.
The Star reported of those physicians, six allegedly charged for services not
rendered five upcoded or billed OHIP using fee codes for more expensive
procedures, and three were charged for medically unnecessary services, which
the plan is not designed to fund, the probe found.
One doctors billing extravaganza was seeing over 100,000 patients in 332 days!
The paper also reported:
Three specialists inappropriately delegated duties for which

they billed OHIP and which they were supposed to perform
themselves to unqualified individuals to undertake.
Six claimed to have worked between 356 and 364 days of the year.
Eight recorded notably high volumes of claims and/or patients.
One radiologist, who worked 332 days, billed for 100,000 patients,
indicating that more than 300 scans were interpreted per day.
9 https://www.thestar.com/news/queenspark/2016/12/30/ontarios-top-billing-doctors-over
charged-ohip-health- ministry-audit-suggests.html

Eleven billed OHIP incorrectly.
An obstetrician/gynecologist billed for seeing male patients.
This list looks suspiciously like the list of criminal fraud activities identified by
the Centers for Medicaid and Medicare in the U.S.
Yet, the Star article mentions the word fraud once and only in relation to a list
of possible actions the Ontario Ministry of Health stated it may take according to
an audit document obtained by the Star.
Why isnt the Ontario Ministry of Health more forthcoming or taking action?

Enter the Ontario
Medical Association
Dr. Virginia Walley, the president of the Ontario Medical Association, said in a
statement to the Star, The assumption that any physician has done something
wrong before a formal process has been completed is detrimental and unfair. It is
essential that all physicians have access to a just process.
Just because a doctor bills a lot, doesnt mean its fraud. It can also mean he/she
is an exceptional professional. In the U.S., there has been overreach in enforcing
healthcare fraud by some government agencies. In some cases, bureaucrats
assume that because a provider bills a lot, there must be fraud involved when
in fact the provider is just very competent.10 This ends up hurting valuable
healthcare professionals.
But for fraud to be almost entirely absent from the Canadian healthcare lexicon
means the pendulum has swung too far in the other direction, especially with
such egregious violations uncovered by the Star.
In fact, a Google search on healthcare fraud in Canada uncovers little current

media or public debate on the subject. If it werent for the Star going after these
high billers in Ontario, there would be almost nothing.
Furthermore, there used to be a private, non-profit organization called the

Canadian Health Care Anti-Fraud Association (CHCAA). It operated for more than
14 years, holding annual meetings on the topic. It was also quoted on the subject.11
Now it is gone. It was recently taken over by the Canadian Life and Health
Insurance Association which has buried the topic of healthcare fraud on its
website. There is only one webpage12 on the topic and it cant be reached from the
websites menuonly from a search from Google.
10 http://www.expressnews.com/news/local/article/In-Medicaid-docs-guilty-until-proven-innocent-
4832728.php
11 http://www.benefitscanada.com/benefits/health-benefits/cchaa-raises-fraud-awareness-64443
12 https://www.clhia.ca/antifraud

Attention, Minister of Justice:
Its time for a federal crackdown
Surprisingly, the Canadian Medical Association Journal published a three-
part series of articles in 2013 about healthcare fraud in the U.S.13, Canada14, and
Europe15. The article on Canada was re-published by U.S. National Institutes of
Health and is very sympathetic to the idea that healthcare fraud in Canada is at
least as great as in the United States and Europe.
The author, Adam Miller, found, as we have, that there is a vast difference
between the handling of fraud in the United States and Canada, and is convinced
that it would be wrong to think it doesnt happen in Canada.
Miller wrote: But it would be entirely

erroneous for Canadians to smugly
Lack of oversight assume that every doctor is squeaky
justification #1: clean, or that the problem of health care
fraud is non-existent north of the 49th
...an intrusion into provincial parallel, as the aggregate level of fraud
jurisdiction over health. by physicians, pharmacies and patients
probably doesnt differ much, whether
its the US, Canada or any other nation
on the planet, according to the Canadian Health Care Anti-fraud Associationthe
now defunct group we just mentioned.
The former director of CHCAA told Miller that the lack of investigation and action
is due to the fact that there is no federal oversight of such activities.
Health Canada told Miller that the notion that there is a need for some manner
of federal involvement or federal mechanism to crack down on healthcare fraud...
would be an intrusion into provincial jurisdiction over health. Miller, indeed,
13 http://www.cmaj.ca/content/185/1/E19
14 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3537805/
15 http://www.cmaj.ca/content/185/1/16

found there is no coordination between provinces or the federal government to
track healthcare fraud.
When Miller interviewed key bureaucrats from Manitoba, Ontario and Alberta,
they simply told him that there is little fraud in their systems.
Ontarios Anti-Rackets Unit
But an investigator with the Ontario Provincial Polices Anti-Rackets Branch

which investigates healthcare fraud in Ontario told Miller, Things that happen
in the US happen in Canada, happen in Europe, and happen anywhere, and in any
kind of fraud where there is a way for people to exploit a service or a system
people will do that.
He went on to say that We dont quantify it. We really dont track that. What we
know is that theres sufficient work out there for our unit to keep going every
year with referrals from the ministry and referrals from other sources to justify
the fact that were here. I think theres a deterrent effect as well when our unit
lays charges... But obviously I dont have that crystal ball to be able to quantify it.
Is the system set up to hide fraud?
So, Canadians are being bamboozled by their own health agencies into a false
sense of security that there is little or no healthcare fraud here.
Why would this be the case?
Here are two possible reasons:
1. Charitably we can chalk it up to public relations. In Canada, the governments

run the whole health care system. So, to uncover and find fraud is an
admission of incompetence and makes them look bad as administrators.
Therefore, they are reluctant to uncover it and to discuss it. This mentality is
detrimental to Canadians and the healthcare system.

2. More cynically, the Canadian system is set up to hide fraud. The fact that
there is no co-operation between provinces and no federal oversight even to
the extent of providing statistics on the problem, means it is a porous system
and it continues this way despite public exposure. Who benefits is a key
question here.
If you need further evidence that fraud is a problem in Canada, please review our
additional resource of articles in the appendix at the end of this paper.
Exposing criminal fraud within our healthcare system must become both an
open topic of discussion and a priority for action by governments in this country.
Citizens must lead the way.
We hope you are sufficiently shocked to raise your voice.
Let us know what you think
What do you think of whats going on? What do you feel should be done? We are
conducting an anonymous survey and would like your opinion. Please click here
to take the survey.

APPENDIX ONLINE CANADIAN FRAUD ARTICLES
The $100 Million Operation

Rip-off of the Ontario Health Insurance Plan.
http://herman.strijewski.com/w5.htm
... While Ontario's bureaucrats and politicians - past and present - are stuck in the throes of
collective amnesia, south of the border NME (National Medical Enterprises) has been giving in
to the crushing weight of evidence against it.
W5 correspondent: "In 1993 National Medical Enterprises settled out of court with a group of
American insurance companies for 214 million dollars. A few months later it was the U.S.
federal government's turn. They collected 379 million dollars to repay Medicare and Medicaid.
The largest fraud settlement in U.S. history."
Texas lawyer James Moriarty can't understand why even today the conservative government of
Ontario isn't flying on down to try to get it's money back.
James Moriarty: "Well, OHIP doesn't have sense to pour piss out of a boot. This is the best
example of fraud in healthcare that there is ever going to be. You are never going to see it this
clearly with this many witnesses, with this many people who acknowledged the fraud in that. I
believe that just like if you owned a bank and somebody robbed the bank you would say 'I want
the money back'."
Jim Wilson is the Ontario Minister of Health: "We've had three legal opinions who say it may
not be the best advice to spend another million dollars of tax payers' money to take the chance to
get the money back."
Sandy Rinaldo: "But so far no one from the Ontario government has contacted any of the
American law firms who successfully collected millions on behalf of their American clients."
When that's story first appeared on W5 last fall it stirred an immediate fury in the Ontario
Legislature. The opposition liberals were eager to tell the Health Minister all about the rip-off.
Opposition speaker: "I will tell him that the W5 story raised some serious questions regarding the
management of OHIP, and frankly the minister's incompetence."
Jim Wilson (Health Minister): "As I told W5 in a 20 minute interview I'd be happy to have any
law firm in the world take on this case."
Sandy: "Happy perhaps, but certainly not hasty. Seven months after we first brought you that
story, the Ontario government has still not launched legal action to recover it's share of the 100
million dollars. The province insists that it is considering a law suit but so far nothing has been
done."
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MDs get jail terms, fines as new police squad targets health fraud
http://www.cmaj.ca/content/163/5/591.2.full.pdf
Physicians are among the targets as Canadas first health care fraud squad operated by police
officers starts cracking down on swindles that have cost Ontario taxpayers millions of dollars.
Since 1998, more than 500 cases have been referred to the Ontario Provincial Police (OPP)
Health Fraud Investigation Unit. The vast majority 395 cases involved alleged fraud by
people who use the Ontario Health Insurance Plan (OHIP) illegally. There were also cases of
double doctoring in which patients used several doctors to obtain controlled drugs by
prescription, as well as 60 alleged cases of fraudulent billing by health care practitioners,
including physicians. If a physician is convicted of fraud, the provincial college automatically
deems it discreditable conduct and has the option of, among other things, suspending or revoking
the doctors licence to practise.
Before 1998, health fraud in Ontario was investigated by a civilian unit within the Ministry of
Health, but results from 2 independent audits caused the ministry to ask the antirackets section of
the OPP to conduct all investigations of fraud involving the use of and payment for health
services. The officers had to study the Health Insurance Act and its regulations, as well as in the
schedule of benefits
The fraud units largest case to date involves 62-year-old Stephen Kai Yiu Chung, who is alleged
to have posed as a physician in Hamilton and is charged with defrauding OHIP of $4.5 million.
Other physicians have already pleaded guilty to defrauding OHIP. Dr. Alexander Scott of
Kingston was sentenced to 30 months in penitentiary after defrauding OHIP of almost $600 000;
he also forfeited $124 000 in an RRSP portfolio. Dr. Donald MacDiarmid of Ajax, who had false
billings worth $150 000, received an 18-month conditional sentence to be served at home and
was ordered to repay the money. He was also fined $100 000 and repaid the clinic where he
worked $150 000. Dr. Gustavo Tolentino, a Toronto general practitioner who practises
psychotherapy, pleaded guilty to defrauding OHIP of $55 000 between 1995 and 1998. He repaid
the money and received a 12-month conditional sentence. (So far, only Scott has been referred to
the Ontario college for a disciplinary hearing.) The most complex case to date is ongoing. It
involves 12 doctors at a Mississauga walk-in clinic who are charged with defrauding OHIP of
about $2 million between Jan. 1 and Dec. 31, 1997.

Health Care Fraud: Who's Problem is it?
http://www.cgib.ca/linkedpages/CHCAA.pdf
Fraud Myth #1 Canada Doesnt Have a Fraud Problem! Where there is money, there is
someone that wants to get that money even if not entitled No verifiable statistics but studies
suggest could be 2 10% of healthcare dollars
What is Fraud? A working definition: Health care fraud is an intentional deception or
misrepresentation that the individual or entity makes knowing that the misrepresentation could
result in some unauthorized benefit to the individual, or the entity or to some other party.
(National Health Care Anti-Fraud Association)
Only a few actual types... Billing for Services Not Rendered Treating outside of Scope of
Practice Allowing Unlicensed Persons to Treat Kickbacks or Referral Payments If illegal
Over-utilization/over treatment
Common Frauds: Identity Theft Fabricated Receipts Misrepresented Claim Details
Unauthorized Alterations of Receipts
Other Fraud Schemes in Canada Double doctoring Office staff fraud Drug trafficking /
diversion
Health care fraud remains uncontrolled, and mostly invisible. this problem represents one
of the most massive and persistent fiscal control failures in their history. For those who profit
from it, health care fraud is not seen as a problem, but as an enormously lucrative enterprise,
worth defending vigorously. Malcolm K. Sparrow Professor, Harvard University - Kennedy
School of Government
Fraud Myth #2 The Insurance Company Just Doesnt Want to Pay The Claim! Insurance
carriers are obligated, contractually and legally, to process claims as your patients employers
directs them Increasing utilization of benefits, especially in tight economic times, forces your
patients employers to make tough decisions about what they can offer in employee benefit plans
Fraud Myth #3 Insurance Carriers Always Think It Is the Provider Committing Fraud!
Absolutely Not! The carriers have seen so many types of fraud by so many different people that
they do not assume anything
CBC TV Investigative report - dental A woman from Brampton charged with 234 counts of
double doctoring and fraud for prescription narcotics A pharmacist charged with obtaining
prescriptions for high priced drugs and paying the patient a percentage of the total prescription
not dispensing the meds however billing ON Gov. for the prescription. A US citizen charged
who was receiving insured medical services for which he was not entitled
Some Case Studies Foot care practitioners charged with submitting fraudulent claims to OHIP
A Pharmacy case fake Norvasc medication being dispensed to clients and the coroner
investigating if this contributed to the deaths of multiple patients A Canadian pair who were

charged over their fake Cancer clinic this affected over 800 patients in Mexico totaling 12
million dollars
The Consequences Premium increases Decrease in the quality of coverage Inability to continue
to provide insurance coverage Things (goods and services) cost more...
Ontarios top-billing doctor charged OHIP $6.6M last year

https://www.thestar.com/news/queenspark/2016/04/22/ontarios-top-billing-doctor-charged-ohip-
66m-last-year.html
-An eye specialist who charged the Ontario Health Insurance Plan a staggering $6.6 million
last year is one of 500 doctors on a secret list billing more than $1 million annually
-Hoskins said hes willing to consider arbitration but insisted many fees, such as for methadone
testing and assessing CT scans and MRIs, are outdated given that technological advances mean
tasks and treatments can now be performed much more quickly.
-The system is badly out of balance with two per cent of doctors mostly a small cadre of
specialists taking 10 per cent of the $11.6 billion set aside to pay doctors for their services,
offices, staff and equipment, he added.
-The top-billing doctor was an ophthalmologist one of three specialties that take in the most
cash, with 85 of them billing more than $1 million.
-Diagnostic radiologists led the pack, with 154 billing $1 million or more. Another 57
cardiologists hit or surpassed the same threshold.
-When they bill more than the budget, the money has to come from elsewhere in the health-care
system, limiting our ability to invest in home care, hospitals, mental health and other services.
-The fee cuts for doctors last September were on top of a 2.65 per cent across-the-board cut the
previous February. There have also been fee cuts targeted at different specialties, and taken
together they add up to 6.9 per cent in cuts, the OMA has said.
-The government cut fees because it is trying to cap the annual physician services budget at
$11.6 billion.
Healthcare Anti-Fraud
https://www.clhia.ca/antifraud
All Canadians pay for healthcare fraud. In North America alone, it is estimated that 2 to10% of
all healthcare dollars are lost to fraud. This means higher costs for everyone.
CLHIA member companies provide important supplementary health coverage to 24 million

Canadians and pay over $30 billion annually for healthcare services delivered to Canadians.
Canada's life and health insurers work hard to reduce healthcare fraud but we need your help!
Reducing healthcare fraud is a team effort. Everyone has an important role to play, whether you
are a patient, healthcare provider or work in law enforcement.
Mississauga doc charged with OHIP fraud

http://www.torontosun.com/2016/09/01/mississauga-doc-charged-with-ohip-fraud
A Mississauga doctor is accused of defrauding OHIP.
OPP say 57-year-old Essam Samy Michael is charged in relation to billings that were submitted
to the Ontario Health Insurance Plan for services that were allegedly either not provided or billed
inappropriately.
Michael is charged with one count of fraud over $5,000.
OPP say the case remains under investigation and police are reviewing evidence to determine the
total loss to OHIP.
Web of deceit: Pharmacist billed province for dead patients- several case examples here
https://www.thestar.com/news/canada/2015/10/03/web-of-deceit-pharmacist-billed-province-for-
dead-patients.html
Billing the province for dead patients and creating fake prescriptions from deceased and retired
doctors all part of a Toronto pharmacists web of deceit.
Using these and other schemes, Amany Hanna bilked more than $200,000 from Ontarios drug
benefit program and was disciplined by the provincial pharmacy regulator.
Hanna is one of 107 health-care professionals found guilty of fake billing during the past five
years. Like almost all of them, she kept her licence.
A Star investigation has found that most health-care providers sanctioned by the provinces
health regulatory colleges for false and misleading billing are allowed to continue practising,
even in cases that resulted in criminal fraud convictions. The 25 regulatory colleges the Star
reviewed also include bodies that oversee chiropractors, dentists and optometrists.
Following a provincial health ministry audit and a police investigation, Hanna pleaded guilty in
2012 to fraud over $5,000, was given a 12-month conditional sentence and was ordered to pay
$60,000 in restitution to the province.
The Ontario College of Pharmacists discipline panel did not revoke her licence. Instead, in Nov.
2014, it issued an 18-month suspension, a reprimand and a requirement to take an ethics course.
She was also ordered to pay $20,000 in costs. The discipline panel called Hannas conduct
disgraceful, dishonourable and unprofessional.

Hanna will be eligible to continue working as a pharmacist next year.
Hanna did not respond to the Stars numerous attempts to contact her, including two detailed
letters left at her home and Highland Creek Pharmacy, the pharmacy in Scarborough her husband
operates.
At Hannas court sentencing hearing in 2012, her lawyer, Marie Henein, said her clients actions
were financially motivated offences and came shortly after Hannas daughter was diagnosed
with relapsing-remitting multiple sclerosis. Henein said treatment for the disease was costing
Hanna and her husband more than $40,000 a year.
Here are the highlights of the provincial health ministrys audit of Hannas pharmacy:
65 claims were made for dispensing products to seven dead patients.
More than 3,500 claims with incorrect identifying information about the prescribing medical
practitioner, including 16 claims from a doctor whose licence to practise had been revoked six
years earlier.
Two drug refill claims that came from a doctor who died 10 years earlier.
118 claims for Pico-Salax, a medication used to clean the bowels before a colonoscopy, for a
patient who had not been prescribed the drug.
55 claims for the antibiotic Biaxin XL for a patient who had been prescribed the drug just three
times.
12 claims for Enbrel, a drug used to treat rheumatoid arthritis and other diseases, over a four-
month period after the patient had stopped taking the medication.
More than $31,000 worth of claims for prescription reviews with patients without any supporting
documentation, such as signatures or dates. In one case, Hanna told inspectors she was sure
she had conducted a review session with a patient two weeks after the patient had died.
Mina, a dental surgeon in St. Thomas, Ont., billed more than $32,000 for surgery that was not
justified by the records over the course of four months, was aggressive and was done for his own
financial gain, according to the Royal College of Dental Surgeons.
Arcuri, a chiropractor in Niagara Falls, was first disciplined in 2010 after his clinic submitted
374 claims, amounting to $24,000, for massage therapy that was never provided. His initial 12-
month suspension was reduced to six months when he completed a record-keeping workshop and
an ethics exam.
When a patient had one appointment with Toronto optometrist Frank Stepec, he billed OHIP
twice. Stepec did that with 32 patients, according to court documents. For another 25 patients,
Stepec billed OHIP for multiple minor assessments that were not provided.
In total, Stepec improperly billed OHIP about $30,000 between Jan. 2007 and Nov. 2009.
He pleaded guilty in criminal court to two counts of fraud under $5,000, was given three months
house arrest and nine months probation. He was also ordered to pay $30,000 in restitution to

OHIP, which he did. Two of his employees were also charged in relation to the fraud, but those
charges were dropped.
In one case, the College of Physiotherapists of Ontario disciplined one of its members because of
what she did privately.
Blumfald, a Thornhill physiotherapist, forged the signatures of other health-care providers on
fake claims for health services and products for herself that she never received. Blumfald
received more than $10,000 in payments from her insurance company, Chambers of Commerce
Group Insurance Plan, for these false claims between 2009 and 2011.
While she submitted the claims for herself outside her physiotherapy practice, the college
discipline panel stated that it felt it had an obligation to deter the profession at large and to
show the public that the profession takes its role as a regulator seriously.
Discipline: Reprimand; six-month suspension, which was lowered to three months when
Blumfald took an ethics course, paid $3,000 in costs to the college and allowed the college to
monitor her practice for three years.
Doctor charged in alleged $2M OHIP fraud

http://toronto.ctvnews.ca/doctor-charged-in-alleged-2m-ohip-fraud-1.2371582
A Brampton doctor is facing several charges after submitting a series of bills to the Ontario
Health Insurance Plan for services police say were not provided.
Ontario Provincial Police said Dr. Gloria Chudnow submitted fraudulent bills between 2011 and
2014 that investigators allege amounted to a $2 million loss for OHIP.
As a result of the investigation, Chudnow, 56, has been charged with two counts of fraud over
$5,000, one count of fraud under $5,000 and one count of making a false statement.
She will appear in a Brampton courthouse on June 19.
Doctor not going to jail for OHIP fraud

http://www.cbc.ca/news/canada/doctor-not-going-to-jail-for-ohip-fraud-1.291316
A Toronto doctor who cheated the province's health plan of almost $1 million has been
sentenced to two years of community service.
Dr. Michael Bogart pleaded guilty last year to billing OHIP for more than $920,000 over six
years for services he never provided. Bogart says he regrets what he did and wants to continue to
practise so he can pay the money back. He claims he over billed because he was trying to please
a former lover who demanded he take him on luxury trips around the world.

During sentencing Wednesday, Ontario Court Justice Peter Grossi acknowledged Bogart is a
gifted physician, but nevertheless sentenced Bogart to 100 hours of community service and three
years probation. Bogart has ten years to repay the money.
Sudbury doctor defrauded OHIP of $800,000: Crown

http://www.thesudburystar.com/2013/09/16/sudbury-doctor-defrauded-ohip-of-800000-crown
Alfred Nkut got his Ontario Health Insurance Plan billing codes from the Ministry of Health in
2004.
Five years later, he was the top filing doctor in the province, a Superior Court trial in Greater
Sudbury heard Monday.
He went from being a low biller to one of the highest-ranked billers in the province, testified
Dr. Laura Amweiler, a medical adviser with the Ministry of Health and Long-Term Care's
Integrity Unit.
The unit is responsible for reviewing claims made from doctors.
From 2008-2009, he was the top-ranked non-psychiatrist for time-based services in the
province.Amweiler was testifying on the first day of the fraud trial of Nkut, a Val Caron
doctor who is facing a charge of fraud over $5,000.
The Crown is alleging that out of close to $1.5 million in OHIP billings Nkut, 48, made to the
ministry from April 1, 2003 to late March 31, 2010, about $800,000 were overpayments.
The billing codes generated more income than the patient volumes would justify, alleged
assistant Crown attorney Philip Zylberberg.
Two former Mount Sinai dental surgeons charged in $200K fraud

https://www.thestar.com/news/gta/2016/03/16/two-mount-sinai-doctors-charged-in-200k-
fraud.html
Criminal fraud allegations against two dentists are just the latest kick in the teeth for the
prominent dental surgeons.
As well as facing several charges of fraud over $5,000, the men have been dogged over the past
10 years by allegations against one or the other of a sexual relationship with a patient, a
complaint that one of them threw a plastic skull during a consultation, and extradition from
Finland.
Provincial police allege that Dr. George Sandor and Dr. Cameron Clokie charged OHIP more
than $200,000 for dozens of surgeries they didnt attend and tacked on extra services to bills on
numerous occasions for work performed at Mount Sinai Hospital.

In 2010, the year the OPP launched its investigation, Sandor left his posts at the University of
Toronto and Mount Sinai hospital and, police say, moved to Finland, where he had defended his
PhD.
He left behind a pending disciplinary hearing for false-billing charges stemming from work at
the Hospital For Sick Children, said Irwin Fefergrad, the registrar of the Royal College of Dental
Surgeons of Ontario.
He skipped town, Fefergrad told the Star. We still suspended him because he didnt pay his
fees, but we will have a hearing.
(Sandors licence to practice was revoked by the college in 2013 for the nonpayment of fees.)
Dentists, like physicians, at Mount Sinai are independent contractors. OHIP billings are their
individual responsibility and they bill directly to OHIP, said hospital spokesperson Sally
Szuster.
She declined to comment further with the case before the courts and the surgeons no longer
affiliated with the hospital.
The charges against Sandor stem from alleged incidents that occurred between January 2006 and
December 2009.
In January he was arrested in Oulu, Finland, and escorted back to Canada in February to face
three counts of fraud over $5,000 two for defrauding OHIP, and one for defrauding Sick Kids.
The total value police allege he gained from the scheme was over $68,000.
Clokie was arrested on March 10 in Toronto. He is facing two counts of fraud over $5,000,
amounting to over $139,000 in value.
Police allege Clokie charged for 75 surgeries he did not attend between January 2007 and
December 2009.
Both men were released on bail. The bail conditions do not include restrictions on practicing,
according to OPP investigator Marc Duval.
Sandor is set to make a court appearance on March 31 and Clokie on March 21.
Divide and conquer

Ontario doctors want binding arbitration. The Wynne government wants a war
http://www.torontosun.com/2016/04/23/divide-and-conquer
f Ontario Health Minister Dr. Eric Hoskins has evidence ophthalmologists, diagnostic
radiologists and anesthesiologists are ripping off OHIP for millions of dollars every year, he
should charge them with fraud.

If hes suggesting an ophthalmologist he singled out Friday for billing OHIP for over $6.6
million in 2015 committed a crime, he should haul that doctor before the courts.
Same goes for the diagnostic radiologist he said billed over $5.1 million and the
anaesthesiologist who billed over $3.8 million.
Ditto for the 500 doctors Hoskins said billed OHIP for over $1 million each last year.
In fact, none of these doctors, whom Hoskins refused to name, broke the law.
Instead, he used them to argue the staggering billings of some medical specialists to OHIP is
the reason family doctors are underpaid and the fee-for-service billing system needs to be
changed.
In other words, Hoskins is using the politics of envy to turn family doctors against specialists and
the people of Ontario against their doctors.
He was also promoting class warfare, just as Ontarios social services minister would be doing
were she, for example, to single out alleged welfare abusers for bleeding the system dry in order
to argue for unilateral government action to cut welfare costs.
Premier Kathleen Wynnes government is locked in a long, bitter dispute with the Ontario
Medical Association, representing Ontarios 28,000 doctors, over how and how much doctors
should be paid.
Hoskins says Ontarios doctors are the best paid in Canada, billing OHIP for an average of
$368,000 (less expenses) per year.
By contrast, the Medical Post magazine says an apples-to-apples comparison of family doctors
working in Ontario to other provinces shows they are in ninth and last place (PEI was excluded),
with an average income of $245,972 annually, and that specialists are no higher than the fourth-
best paid in a wide variety of categories.
Disagreements of this nature with essential service workers are typically settled through binding
arbitration.
In January, Wynne agreed to binding arbitration to settle contract disputes with the provinces
6,000 jail guards and probation and parole officers, in return for them giving up the right to
strike.
Toronto doctor charged in alleged OHIP fraud

http://www.citynews.ca/2016/08/24/toronto-doctor-charged-in-alleged-ohip-fraud/
A Toronto doctor has been charged with fraud in an alleged scheme involving Ontario health
insurance billings.
Provincial police say the charge stems from OHIP billings for services that were either not
provided or billed inappropriately.

They say Dr. Ranjit Kumar Chandra, 78, is charged with fraud over $5,000 and an arrest warrant
has been issued as he is believed to be out of the country.
The case is still under investigation and police say they cant yet specific the total value of the
alleged fraud.
Mississauga doctor Carlo Meola facing fraud charges: OPP

http://www.cbc.ca/news/canada/toronto/mississauga-doctor-carlo-meola-facing-fraud-charges-
opp-1.3391860
A Mississauga doctor is facing fraud charges after an investigation by Ontario Provincial Police.
The OPP anti-rackets branch says the investigation centred on the AIMS Multispecialty Clinic.
The provincial health ministry referred the case to the OPP's health-fraud investigation unit after
it received complaints about patients being unnecessarily referred to doctors at the clinic.
Dr. Carlo Meola, 59, is charged with fraud over $5,000.
Police did not estimate a value of the fraud other than to describe it as "significant" and to say it
had been occurring regularly.
Meola appears on the College of Physicans and Surgeons of Ontario public register as practicing
at an address on Queensway near Hurontario in Mississauga, listed as the Multi-Specialty Walk-
In Clinic.
Meola is scheduled to appear in court on Mar. 1.
Patients should know what doctors are billing OHIP

http://www.torontosun.com/2012/11/15/patients-should-know-what-doctors-are-billing-ohip
Patients never get to see the what doctors are billing.
Not only that, weve no idea how much were paying for hospital services or trips to walk-in
clinics.
We dont value something when we dont know how much it costs.
And how do we know were getting good value for our dollars when we dont even know the
cost of the service?
That simple measure of sending out a statement to patients at the end of the year for services
theyve received would do more to lower health costs than the piddly $100 million in savings the
government claims to have negotiated with the Ontario Medical Association (OMA) in its latest
deal.

The only thing we do know is that the deal adds $100 million to doctor salaries, but that will be
offset by $100 million in supposed savings.
We know precious little about this deal and with the legislature prorogued, theres no mechanism
for us to find out the details.
Whitby-Oshawa Tory MPP Christine Elliott is troubled by the lack of accountability.
Im concerned that were adding another $100 million to the overall physician compensation
package at a time when we have a $15-billion deficit, she told me in an interview.
Health Minister Deb Matthews says the $100 million will be made up by savings to the system
but those savings arent from the $11.2 billion we spend on doctor salaries. Its from the rest
of the $49-billion health budget a drop in the bucket. And again, no accountability as to where
theyre coming from.
Elliott says sending out health statements is a good idea.
Members of the public need to understand what the real cost is of the health services they
receive, she said.
I think we really need to do something to give members of the public a realistic idea of how
much the cost is of services that they individually receive because it is a very scarce resource and
we need to make sure that everybody uses that resource appropriately.
New Democrat health critic France Gelinas says shes fuming that she knows none of the
details of OMA deal because the House is shut down, no committees are operating and theres no
question period so opposition parties can hold the government accountable for their actions.
Youre talking about an $11.2-billion deal in my portfolio, and I know nothing about it, she
said.
At one time, sending out a yearly statement to the estimated seven million Ontarians who use the
health system every year would have been a nightmare, she says.
Now, with e-mail and secure websites, she says technology has made it simpler.
There are huge parts of the health-care system where we have no idea how much anything
costs, she said.
Look, who hasnt opened a credit card or utility bill thats had an error in it?
Mistakes happen. But without the fail-safe check of the consumer checking his or her bill, how
do we know OHIP is being billed accurately for the services were using?
Give doctors binding arbitration

http://www.torontosun.com/2016/04/28/give-doctors-binding-arbitration

In that context, were at a loss to understand what Health Minister Eric Hoskins point was last
week in throwing gasoline on the fire by implying high-priced medical specialists in Ontario are
the reason other parts of the health care system are starved for necessary funds.
Especially so since Hoskins did not claim any of the 500 specialists he cited for billing the
system for more than $1 million annually (out of 28,000 doctors) were committing fraud.
In fact, many doctors must pay out of their gross billings to OHIP for the costs of maintaining a
practice things like office rent, hiring staff and purchasing equipment which lower their
take-home pay.
It would appear the solution to the two-year deadlock in negotiations between the province and
the Ontario Medical Association, is relatively easy to resolve.
Because doctors cannot strike, they want their contract dispute with the government sent to
binding arbitration if an agreement cannot be reached at the bargaining table.
Given that this is the norm for other essential workers in Ontario such as police, firefighters and
TTC employees, why is the province refusing to agree to binding arbitration for doctors?
Doctor payments in Canada reach $25B

http://www.cbc.ca/news/health/doctor-supply-cihi-1.3732029
-Physicians in Canada were paid a total of $25 billion in 20142015, up from $24.1 billion
during the previous period, according to a new report.
The average payment per physician remained virtually unchanged at $339,000 nationally,
the Canadian Institute for Health Information(CIHI) said Tuesday in its annual report.
Total gross payments to physicians represent an increase of 3.7 per cent over the previous year
the second-lowest increase since 19992000.
To put the $25 billion in total gross payments to doctors into perspective, Canada spends $18 to
$20 billion a year on defence.
The average gross clinical payment per physician varied across the country. The average gross
payment per physician was $339,000, ranging from $258,000 in Nova Scotia to $366,000 in
Alberta. Ballinger said 2015 was the first year Alberta topped the country in average gross
clinical payment per doctor.
For the first time, the institute provided a breakdown of the average amount by physician
speciality. For example, nationally:
Family physicians $271,000.
Medical specialists $338,000.
Surgical specialists $446,000.

CBC INVESTIGATES
Millions of Canadians don't have to be told if health information breached
http://www.cbc.ca/news/health/health-records-privacy-breaches-1.3780963
The personal health information of hundreds of patients is breached every year, but most
Canadians live in provinces where health-care providers don't have to tell victims.
A CBC News investigation found six provinces, which have a combined population of about 20
million, have no legislation in place requiring hospitals, doctors and other health-care
providers notify patients of a breach of their medical files.
The legislative landscape across the country is uneven.
B.C., Alberta, Saskatchewan, Manitoba, Quebec and P.E.I. don't have legislation that requires
health-care providers to notify patients of a breach.
In the jurisdictions that do have some form of notification requirement, the legislation often has a
minimum harm threshold. In Yukon, for example, the bar for notification is "risk of significant
harm as a result of the security breach."
The information CBC News gathered from privacy watchdogs and health authorities from across
the country suggests there were more than 1,300 breach reports in 2015, compared to 922 in
2014. The numbers include provinces where custodians of health information don't have to
report breaches to their respective privacy watchdogs.
Health Care Cost Drivers: The Facts.

https://secure.cihi.ca/free_products/health_care_cost_drivers_the_facts_en.pdf
In total, public-sector spending on health care reached $121 billion in 2008, an average annual
increase of 7.4% since 1998. According to the latest forecasts presented in National Health
Expenditure Trends, 1975 to 2011, 1 an annual report from the Canadian Institute for Health
Information (CIHI), public-sector health spending as a share of gross domestic product (GDP) is
projected to be 8.1% in 2011 (Figure 1).
It is helpful to examine the story of health spending after adjusting for inflation and population
growth. As the following figure illustrates, there have been three phases in the growth of public-
sector health spending since 1975: a growth phase from 1976 to 1991; a second period of
retrenchment and disinvestment from 1992 to 1996; and a third phase of growth that averaged
3.5% per year from 1997 until 2008.

Actually, Canada, health care isnt free
http://www.theglobeandmail.com/life/health-and-fitness/health/actually-canada-health-care-isnt-
free/article4230286/
Last year in Canada, we spent an estimated $200.5-billion on health services. About 70 per cent
of the total, $141-billon, was paid from public coffers and the other $59.5-billion with private
insurance and out-of-pocket.
The free part, presumably, is the public piece of the pie
Canadian health care is high price yet low quality

http://www.torontosun.com/2016/10/29/canadian-health-care-is-high-price-yet-low-quality
One out of every four dollars spent by governments in Canada goes to maintaining our free
health care system. It is far and away the provinces largest expense.
Of our total GDP nearly $2 trillion almost 11% is directed by governments towards health
care. That works out to well over $200 billion every year. Of the 28 industrialized countries in
the world with universal health care system (the U.S. doesnt count), Canada ranks third in health
care spending. Only the Netherlands and Switzerland devote greater percentages of their GDP to
hospitals, doctors, health workers, diagnostic machinery and drugs.
For instance, of the 28 countries surveyed, Canada is dead last in the number of hospital beds per
1,000 residents. We have fewer than two beds per 1,000 residents. That puts us behind Slovenia,
Estonia and the Slovak Republic.
Leaders Korea and Japan have more than six per 1,000.
The number of acute care beds isnt always a direct sign of a failing health care system.
We are 24th in the number of doctors per 1,000 population, 13th in the number of nurses and
20th or lower in the number of MRIs, CT scanners, PET scanners, mammography equipment and
other high-tech diagnostic tools.
So what is the problem?
Its not money, obviously. We pump plenty of money into health care about $5,700 per man,
woman and child. The amount spent on health is nearly four times the amount spent on all new
homes and buildings constructed across the country in a year.
And it is not those who work in the system. Canadas doctors, nurses, physios, lab techs and so
on rank highly on most international measures of training, skill and competence.

Health-care savings are complete fiction
http://www.kelownadailycourier.ca/opinion/columnists/article_a390c084-9d6a-11e6-8b7d-
1797d34a29a7.html
Less lovely is a report, from B.C., that Canadians with broken hips are more likely to die if they
seek treatment at a small- or medium-sized community hospital, compared with large or teaching
facilities.
For every 1,000 patients admitted with a hip fracture, 14 more die at medium-sized centres. That
number increases to 43 more at small community hospitals.
Small hospitals have fewer than 50 beds, medium community hospitals have between 50 and 199
beds while large community hospitals have more than 200 beds, according to the study.
Fewer beds, staff and less equipment are cited as reasons for the outcomes.
Physician Assistants Could Result In Significant Savings For Canadian Health Care
System: Report
http://www.inews880.com/syn/60/177190/physician-assistants-could-result-in-significant-
savings-for-canadian-health-care-system-report
In 2015, the health care system cost Canadians $219M, with physician services, hospitals and
drugs making up 60% of the spending.
The report says the PAs could step in and complete more routine tasks, to free up the physicians
time. The Board says if PAs are able to relieve more than 30% of physicians time in all areas,
this could represent $620M in costs savings for the health care system
Canada one of highest spenders among universal health-care countries, but performance
ranks modest-to-low
http://www.marketwired.com/press-release/canada-one-highest-spenders-among-universal-
health-care-countries-but-performance-ranks-2170164.htm
Canada spends more on health care than almost every other comparable country with universal
care, with only middling to poor performance to show for it, finds a new study released today by
the Fraser Institute, an independent, non-partisan Canadian public policy think-tank.
he study compares 28 universal health-care systems in developed countries, spotlighting several
key areas including cost, use of resources, access to care and treatment, clinical performance and
quality, and the health status of patients.
In 2012, the most recent year of readily comparable cost data, Canada's health-care spending as a
share of GDP (10.6 per cent) ranked third highest-after adjusting for age -- behind only the
Netherlands and Switzerland.

But despite the high cost, Canada ranked poorly on a number of important indicators. For
example, Canada ranked 24 out of 28 countries for number of physicians (2.59 per 1,000
people), and last for the number of acute care beds (1.77 per 1,000 people).
When it comes to critical technological resources, Canada ranked 18 out of 26 for the number of
Magnetic Resonance Imaging (MRI) machines with 9.2 MRIs per million people. Japan ranked
first with 36.7 MRIs per million people.
As for wait times, Canada ranked last for the percentage of patients (29 per cent) who waited two
months or more for a specialist appointment. Canada ranked second-last for the percentage of
patients (18 per cent) who waited four months or longer for elective surgery. Switzerland, the
Netherlands and Germany all reported significantly shorter wait times.
"Despite Canada's high health-care spending, wait times remain a defining characteristic of
Canadian health care," Barua said.
"To improve Canada's health-care system, policymakers should learn from other successful
universal health-care countries, for the benefit of Canadians and their families," Barua added.


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PART 1 OF THE WHITEPAPER SERIES

Our healthcare system is haemorrhaging $37.5 million per day

Is Canada really a fraud-free

Lets look at the American experience for a moment.

Medicare and Medicaid are two different government-run

Medicare is a federal program that provides health coverage if you

2017 MONITOR TELEGRAM | All Rights Reserved | PAGE 2

Tricare, formerly known as the Civilian Health and Medical

2017 MONITOR TELEGRAM | All Rights Reserved | PAGE 3

Payments (in cash or in kind) in return for Medicaid numbers,

Common Fraud Schemes

Billing for phantom patients,

2017 MONITOR TELEGRAM | All Rights Reserved | PAGE 4

We cannot find a comparable statistic in relation to Canada. However, the CHLIA

So how much is bleeding from the

We are losing healthcare funds at an incredible rate:

$13.7 billion per year8

Why not in Canada, considering the figures above?

2017 MONITOR TELEGRAM | All Rights Reserved | PAGE 5

A Toronto Star story from December 30,

The paper also reported:

Three specialists inappropriately delegated duties for which

2017 MONITOR TELEGRAM | All Rights Reserved | PAGE 6

2017 MONITOR TELEGRAM | All Rights Reserved | PAGE 7

In fact, a Google search on healthcare fraud in Canada uncovers little current

Furthermore, there used to be a private, non-profit organization called the

2017 MONITOR TELEGRAM | All Rights Reserved | PAGE 8

Miller wrote: But it would be entirely

2017 MONITOR TELEGRAM | All Rights Reserved | PAGE 9

Ontarios Anti-Rackets Unit

But an investigator with the Ontario Provincial Polices Anti-Rackets Branch

Is the system set up to hide fraud?

Why would this be the case?

Here are two possible reasons:

1. Charitably we can chalk it up to public relations. In Canada, the governments

2017 MONITOR TELEGRAM | All Rights Reserved | PAGE 10

We hope you are sufficiently shocked to raise your voice.

Let us know what you think

2017 MONITOR TELEGRAM | All Rights Reserved | PAGE 11

The $100 Million Operation

Ontarios top-billing doctor charged OHIP $6.6M last year

CLHIA member companies provide important supplementary health coverage to 24 million

Mississauga doc charged with OHIP fraud

Doctor charged in alleged $2M OHIP fraud

Doctor not going to jail for OHIP fraud

Sudbury doctor defrauded OHIP of $800,000: Crown

Two former Mount Sinai dental surgeons charged in $200K fraud

Divide and conquer

Toronto doctor charged in alleged OHIP fraud

Mississauga doctor Carlo Meola facing fraud charges: OPP

Patients should know what doctors are billing OHIP

Give doctors binding arbitration

Doctor payments in Canada reach $25B

Health Care Cost Drivers: The Facts.

Canadian health care is high price yet low quality

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