Maintaining Eligibility with Insurance Companies

Wednesday, April 10, 2019, 03:35 PM

Holistic health practices are vital to the health and wellness of Canadians. A publication on complementary and alternative medicine reports that 79 per cent of Canadians have used at least one complementary or alternative therapy sometime in their lives, with 44 per cent of all Canadians having tried massage therapy.

As a holistic practitioner, being an eligible service provider with insurance companies means that your clients can have treatments covered through their extended health benefit plans.

More Canadians are able to access complementary health treatments, such as massage therapy and reflexology, when they are not an out-of-pocket expense.

A practitioner reviews an intake form with a client.

To maintain your eligibility with insurance providers, you must meet the company's expectations for professional practice, preventing insurance fraud and benefit plan abuse.

Practitioners and clinics can lose their eligibility (or be delisted) with an insurance company if found to be non-compliant with the provider's expectations.

What is Insurance Fraud?

To detect fraud and abuse, insurance companies have investigators that gather claims data, conduct audits on service providers and clinics, and use analytics to identify irregular billing patterns.

Examples of insurance fraud include:

  • submitting claims for treatments that were never given
  • falsifying receipts
  • falsifying client records

Examples of insurance abuse include:

  • using up a client's benefits over a very short period of time
  • submitting a pattern of claims for services not medically necessary.

The National Post reported in 2018 that Canadians underestimate the consequences of health benefits fraud. While 75 per cent of Canadians believe that the punishment for benefits fraud is higher premiums or reimbursing claim payouts, other consequences include job loss and criminal charges.

Practitioner Responsibilities

To ensure that you remain an eligible service provider with insurance companies it is crucial that you adhere to the standards of practice for your modality. Insurance companies need to know that as a practitioner you will:

  • obtain and update client intake and health history forms
  • maintain adequate treatment/clinical/SOAP notes
  • keep attendance and financial records
  • follow appropriate receipting standards and maintain accurate billing practices
  • have professional and appropriate advertising
  • be compliant with insurance company audits.

If you have questions about your ethical and professional responsibilities as a practitioner, or you are a client and have concerns about a treatment, the NHPC offers one-on-one practice management advice to both members and the public.

Protecting Yourself

If you work at a clinic where someone else writes out the client's receipt or completes the financial transactions, you must ensure that they meet the insurance company's expectations as well. It is your responsibility to ensure your name and association number are not used fraudulently.

Practitioner discusses records with client.

To protect yourself, follow these best practices:

  • do not sign blank treatment and assessment plans
  • maintain good records of the services you provide in order to refute fraudulent claims
  • audit your records regularly to spot any suspicious activity
  • report suspicious activity to the insurance company, the Canadian Life & Health Insurance Association (CLHIA), and the NHPC.

Paul Donovan, NHPC Industry Relations Manager, explains that "professional associations, including the NHPC and massage therapy regulatory colleges, ultimately have no authority over insurance companies and their decisions to delist providers."

For more information regarding insurance best practices, contact the NHPC Industry Relations Team.

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