Day: January 20, 2020

Health Care Fraud: Applying Privacy Legislation to Investigations

The property and casualty insurance industry experiences staged accident injury claims by local gangs. There is also international experience with transnational organized crime bilking the payment systems at more complex levels.  In both cases it can involve physicians in public plans receiving kickbacks for diagnoses leading to the bilking of private insurance plans. 

s a case study, Ontario privacy legislation was reviewed for conditions and limitations on public and private health care exchanges of personal information for cooperating in investigations.

The Ontario Personal Health Information Act, 2004 defers to the Ontario Freedom of Information and Protection of Privacy Act (FIPPA) for these conditions. FIPPA does not prohibit inter-agency sharing of personal information for investigative purposes. What it does do,  is provide for how this information is to be shared.

Part III, Section 42  of FIPPA states: “An institution shall not disclose personal information in its custody or under its control, then details exceptions.

These exceptions allow institutions to disclose personal information to a law enforcement agency, if:  the disclosure is to aid in an investigation undertaken by the institution, or to an agency, with a view to a law enforcement proceeding, or (ii) there is a reasonable basis to believe that an offence may have been committed and the disclosure is  to enable the institution or the agency to determine whether to conduct such an investigation.

The challenge in combating organized crime activity; private insurers generally report potential crimes to the municipal police department where the offences have occurred, resulting in severe limitations on getting at organized crime groups. They are not concerned about their soldiers being arrested, convicted and incarcerated. There are always more soldiers.

One way to coordinate public/private sector effort is through a  centralized strategic and tactical health crimes analysis body coordinating and launching multi-agency intelligence probes and investigations. The public police can use the  extraordinary powers of search and seizure for conducting complex investigations and obtaining additional information, including public and private insurers, police and other sources.

A precedent for an integrated health agency/police cooperation approach has already been established in Ontario. During the Harris administration, the Ministry of Health and Long-Term Care disbanded its internal investigations unit and contracted with the Ontario Provincial Police, Anti-Rackets Branch to conduct criminal and regulatory investigations on behalf of the Ministry.

What would preclude private insurers co-contracting with the Ontario Provincial Police, Anti-Rackets Branch to provide the public and private health care insurers with a strategic and tactical crimes analytical service?  When recognizing an organized crime/gang pattern, an “Anti-Rackets tactical intelligence and investigations team. An alternative for strategic intelligence might be Criminal Intelligence Services Ontario.

The unanswered question is whether the Ontario government and private insurers have the appetite to go after transnational organized crime and provincial level gang activity gaming the public and private health care plans.