Health Fraud Investigations

In April 1998 the Ontario Ministry of Health and Long Term Care signed an agreement with the Ontario Provincial Police to fund a team of OPP officers to investigate fraud committed against the payment and delivery of health services and products in Ontario. This agreement remains in place today.

This multi-disciplinary team consists of 28 dedicated positions from Anti-Rackets, Drug Enforcement, and E-Crimes.  Officers are deployed in Orillia, Toronto, London and Kingston to respond to investigations through out the Province of Ontario. Above their required police training, they receive training in economic crime, and even more specialized training in health care fraud. The Health team concentrates on investigations related to Criminal Code offences, Health Insurance Act offences and Controlled Drugs and Substances Act offences where the Ministry of Health and Long-Term Care is a victim.

Health fraud investigations are categorized based on three classifications of health care services: Provider Fraud (physicians, pharmacists, optometrists), User Fraud and Drug Diversion.

Provider Fraud involves crimes related to fraudulent billings to the Ministry of Health and Long-Term Care by medical providers. Some examples of fraudulent billing are billing for medically unnecessary services or products or billing for services or products that were never preformed or supplied. Another common fraud is known as "upcoming" — billing for a more expensive service or product than the one actually provided.

User Fraud involves crimes related to receiving services or products that they are not entitled to or any crimes involving Ontario Health Cards.  Some examples of User fraud are Ontario residents who "lend" their cards to non-residents of Ontario, anyone who falsely obtains a legitimate health card, anyone who receives health services or products illegally in Ontario or anyone who falsely claims for medical expenses that occurred while out of Ontario.

Drug Diversion involves crimes related to fraudulently obtaining prescriptions that residents are not entitled to. Some examples of drug diversion are residents that see more then one doctor for the same condition to receive multiple prescriptions or residents that fake a condition to receive a prescription. The fraudulently gained prescriptions are used for the residents’ own addictions or converted to money.

In addition to investigating health fraud, the Anti-Rackets Health Team is partnered with the Ministry of Health and Long- Term Care’s Fraud Programs Branch in providing training in fraud detection and prevention to Ministry front line staff and public education forums.