Fraud Happens: How To Prevent It and What To Do About It
While benefit fraud is carried out by a small number of people, the effects on your group benefit plan can be very costly. Benefit fraud comes in all shapes and sizes and involves not only plan members but could also involve service providers. Fraud patterns may include some or all of the following: - claims services not actually received;
- providers performing services that are outside of the scope of their licensing;
- services or treatment over and above what is needed;
- illegal referral payments or kickbacks; and
- unlicensed individuals performing insurable services.
In this session you will hear from carriers what they are doing to detect and prevent benefits fraud from happening. You will also learn what measures they take to protect group plans and what are they doing to recover funds owed as a result of fraud. Sometimes, despite robust prevention and detection efforts, benefit fraud still happens. The second half of this session will examine what measures are available to an employer when an employee has committed benefit fraud. Can an employer terminate the employee for benefit fraud? And what information should the employer obtain from the benefits plan provider in order to support any discipline that is imposed? The morning’s session will conclude with a discussion of the options available to employers and the steps that must be taken in order to successfully discipline an employee who has committed benefit fraud.
Speakers:  | Michael Byerley
Owner, Michael Byerley Consulting Inc
Michael’s firm provides consulting services in Food Safety, Occupational Health & Safety, Human Resources and Customer Service for the Retail and the Restaurant Industry. His major client is SSP Canada Inc., a restaurant management company with 24 operations at Toronto Pearson. He is managing all HR functions, including labour relations, benefits, employee assistant programs, food safety and occupational health & safety. This is for 650 employees in Toronto and also supports the onsite operations persons with these services for the other Canadian operations in Vancouver, Winnipeg and Montreal.
Previously Michael was with both Sobeys Groceries and Compass Group Canada where he was responsible for ensuring that all Food Safety programs were effectively executed at the store and warehouse level. He managed a team of Food Safety Specialists to deliver programs, monitor compliance and develop action plans to address scorecard and audit gaps. The team provided coaching and feedback to Local Market managers and staff in order to continuously improve execution of Food Safety standards, practices and regulatory requirements. | | | |  |
Shelley Frohlich
Director of ISU, Fraud Risk Management, Sun Life Financial
Shelley oversees the Investigative Services Unit responsible for investigation, fraud detection and prevention through strategic direction and fraud risk management within Group Benefits. Under her leadership and through intelligence led anti-fraud strategies, there is a focus on plan member investigations as well as the profiling of medical and dental providers and facilities.
Shelley has been with Sun Life for six years and has worked in the investigation field within the insurance industry for the last fifteen years, including participating in court and regulatory hearings. | | | |  |
Amanda J. Hunter
Partner, Hicks Morley Hamilton Stewart Storie
Amanda Hunter is a labour and employment lawyer in Hicks Morley’s Toronto office. She advises clients in both the private and public sector on all labour, employment and human rights issues. She has a particular expertise in the application of the Ontario Employment Standards Act, 2000 and minimum standards legislation in other provinces and the Canada Labour Code, providing strategic advice on compliance issues including facilitating audits and mitigating non-compliance risks.
She regularly appears as counsel on behalf of employers before the courts, labour arbitrators, the Ontario Labour Relations Board and the Human Rights Tribunal of Ontario.
| | | |  | Andrew H. Kautz
Manager - Special Investigations Unit, Great-West Life Assurance Company
Andrew has more than 30 years of investigative experience and since 1991 has dealt primarily with employee theft and fraud investigations. His work has taken him across Canada and into the United States investigating frauds ranging from a few hundred to several million dollars, including loan frauds, Ponzi schemes, phony vendor scams and investment dealer frauds. In addition to investigation, he pursues recovery from perpetrators as well as third parties that may have played a role in the fraud scheme. These efforts include the recovery of funds from Nigeria that had been sent to this country by a dishonest employee in response to one of the infamous Nigerian Letters.
Andrew is a member of the Faculty of the Association of Certified Fraud Examiners and lectures regularly on fraud related topics to a wide range of groups including fraud investigators, risk management professionals and members of the insurance industry. He has designed policies and procedures related to fraud prevention and was a contributor to the Association of Certified Fraud Examiners publication, Fraud Casebook: Lessons from the Bad Side of Business, a selection of fraud case studies. | | |  cropped.jpg?mw=110) | Michele Madore
Supervisor, Benefit Utilization Analysis Department, Green Shield Canada
Michele has a background in Pharmacy and is also educated in Business and Management Studies. In 1996, Michele joined Green Shield Canada where she held positions in both the Drug Claims & Drug Special Authorization Department. From there, Michele moved to the Benefit Utilization Analysis Department where her responsibilities were to identify misuse, abuse and fraudulent activity within benefit plans; carry out both plan member and provider investigations; and to develop and implement risk management strategies.
In 2012, Michele was promoted to a Supervisory role within the Benefit Utilization Analysis Department where she continues to work in protecting benefit plans against misuse and abuse, as well as overseeing the audit function for plan member e-claims. Michele is actively involved with several working groups within the Canadian Life & Health Insurance Association (CLHIA) striving to educate and create awareness in the fight against health care fraud.
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