Insurance Benefits Abuse & Fraud
Insurance abuse and fraud actually is a big deal. Overall it costs the insurance industry and employers millions of dollars each year.
Potential consequences for members on a plan:
- You may not intially feel the consequences of insurance abuse and fraud directly, eventually they present themselves through increased premiums or by the removal of services that the plan once covered.
- You maybe investigated by your employer.
Potential consequences for massage therapists:
- Insurance companies may decide not to accept claims and/or not allow a massage therapist to direct bill anymore.
- MTAM (and other associations) may cancel a massage therapist's membership when they have committed fraud.
- The person found guilty of committing fraud can be charged with fraud under Criminal Code section 380(1)B, which is fraud under $5,000. If convicted, the maximum fine is $5,000 and/or up to 6 months in jail.
What is considered insurance abuse?
- Receiving services that are not part of a therapeutic treatment for illness or injury and claiming it under insurance benefits
- Excessive use of benefits (i.e., using all benefit coverage in the month of December, with no treatment justification)
- Claiming gifts for insurance reimbursement (i.e., gift certificates, promotions)
What is considered insurance fraud?
- Using a family member’s unused massage therapy benefits (i.e. using their name on your official massage therapy receipt)
- Submitting claims for services that are not part of a massage therapist’s scope of practice (e.g., pedicures, nutrition counselling, osteopathic manual treatments, body scrubs, etc.)
- Submitting a claim for a massage therapy treatment that was not received (i.e., claiming receipts for a missed appointment or cancellation fee)
- Forging or altering a doctor’s note
- Submitting a late fee or a cancellation fee for reimbursement under a plan
- Using a massage therapist’s professional identification number without their knowledge
- Altering receipts in anyway
Things clients can do to prevent insurance abuse and fraud
- The details of each plan vary -- so please read your benefit plan from cover to cover, and know the specifics.
- Always review your receipts to ensure that the services and details of your treatment are properly reflected.
- If you are asked to sign documentation, read it thoroughly, know what you are agreeing to and never sign a blank document.
- Keep records of your appointment dates and receipts for your co-pay portion as proof of payment/attendance.
Things massage therapists can do to prevent insurance abuse and fraud
- Read your benefit provider agreements and know what your responsbilities are.
- Educate clients when they make requests that are considered insurance abuse or fraud. Let them know that you could lose your ability to bill to an insurer, be charged hefty fines, or worse, lose your ability to practice massage therapy.
- If you become aware of fraudulent practices by other healthcare practitioners or clinics; it is your professional responsibility to report this to the affected insurance company.
- Manitoba Blue Cross: Protect Your Business – Provider Fact Sheet
- Fraud Prevention - Ways to protect your practice from health care fraud
MTAM poster
Reporting Insurance Abuse & Fraud
Should you come across a situation that has you concerned, you can contact MTAM at 204.927.7979, for advice, or you can reach out to our friends at the Canadian Life and Health Insurance Association (CLHIA). A list of fraud hotlines for various insurers can be found on CLHIA's web page:
FAQ's
Q. My husband/son/daughter never use their insurance coverage. Can I get a receipt in their name so I can claim it under their coverage?
A. Receipts need to be issued in the patient’s name. Making a claim under someone else’s coverage, even if they are on the same insurance plan as you, is fraud.
Q. I want to buy a gift certificate, but I want the receipt to say I purchased a massage, not a gift certificate, that way I can claim it on my insurance and get reimbursed.A. Receipts are required to accurately reflect what was purchased (in this case a gift certificate or gift card). Insurance coverage does not cover gift card purchases.Q. Yesterday was the last day my insurance was valid, can you backdate the receipt?
A. Receipts can't be altered in any way and must reflect the date that the service was rendered.Q. Sorry I missed my last appointment. Can you just bill my insurance company for it?A. Insurance companies will not pay for missed or cancelled appointments.
Q. Can you charge my insurance extra so that I don’t have to pay anything out of pocket? For example, you charge $70.00, the insurance covers 80%, but you bill the insurance company $87.51 so that the insurance company pays out the full $70.00?A. No. You cannot overcharge the insurance company. Rates should be posted in your clinic and as a part of an ethical practice a massage therapist should charge the posted rate. It is considered insurance abuse to have a separate billing schedule for those with insurance benefits.
Q. Can I charge an administrative fee for direct billing and include this in my fee for service? Example if a client pays cash their massage is $75 for an hour, but if I have to direct bill it is $80 for an hour.A. Most insurance companies have policies in the place that prohibit charging fees for direct billing, review your provider agreement for details. Insurance companies view direct billing as a benefit/convenience for both their clients and RMT's, direct billing can save clinics and RMT's hundreds of dollars annually in debit/credit machine charges. It is also considered insurance abuse to have a separate billing schedule for those with insurance benefits.
Q. Since you also do nutritional counselling (or another service), can you bill that under massage therapy?A. RMT's can not misrepresent a treatment on a receipt. Even if the RMT has additional education in nutritional counselling, because this modality is outside of the scope of practice for massage therapy, they cannot bill for it under massage therapy. Refer to the member information and insurance page in the members only section for information on what modalities are covered.Q. I won’t use all my insurance coverage this year. I have enough money left on my insurance for two more treatments. Can you put those through now and I’ll use up the money in the new year?A. Pre-paid appointments are not billable to insurance companies. They will only accept receipts for treatments that have actually occurred. The date on the receipt needs to be the same date that the patient received a massage.Q. I’d like to give you a tip. Can you add it to my massage amount and put it through my insurance?A. Thank you for the compliment, insurance does not cover tips, and the best tip you could give an RMT is to refer a new client!Q. My insurance requires a prescription, but I don’t have one. Can you put my claim through and I’ll get you a prescription later?A. If you require a doctor's prescription to access massage therapy benefits please note that prescriptions need to be issued before, or on the date of the massage for your insurance company to approve your claim.Q. Since you’re an RMT and work in a spa, can you bill my pedicure as a massage treatment. I don’t use all my massage coverage anyway.A. RMT's can not misrepresent a treatment on a receipt. Even if the RMT is an esthetician, because this modality is outside of the scope of practice for massage therapy, they cannot bill for it under massage therapy. Refer to the member information and insurance page in the members only section for information on what modalities are covered.
Q. Your best friend is going through a hard time financially, she’s asked you to put through claims for massages that she didn’t receive and wants you to give her the money for those claims.A. Regardless of the reasons, you cannot put through claims for treatments that you did not perform.
