Benefits fraud affects us all – here’s what you can do to help prevent it.
What is benefits fraud and abuse?
Benefits fraud and abuse is the misuse or overuse of a benefits plan, most commonly for the purposes of financial gain. That might mean someone is using their plan in a way other than the intended purpose of a benefit, or maybe seeking reimbursement for a good or service they are not entitled to. Fraud can can take many forms, ranging from improper billings, excessive charges, billed services and supplies not supported by an evidenced medical need, or even deceitful claims for products or treatments that were never really provided.
Fraud could be committed by plan members, their dependents, or even healthcare providers. Whoever the wrongdoer, these activities have serious costs and impacts to the value, affordability, and sustainability of benefit plans for sponsors and members alike.
Fraudulent claims and plan misuse impact more than just your insurance service provider. These actions impact everyone, leading to higher premiums, reduction of benefits or coverage, or the elimination of benefits plans altogether.
Most plan members, service providers, and medical suppliers are honest and proper in their dealings with insurance providers; however, there are countless rationalizations, opportunities, and pressures that may drive people to commit such acts, like financial need, views of entitlement, or even active encouragement from trusted sources. Whatever the justification, these actions are simply wrong, unethical, and often outright illegal, with far-reaching consequences often not considered.
What are we doing to prevent fraud?
Our strategic approach to fraud starts with a zero-tolerance policy. We’re resolute in our efforts to protect the integrity and sustainability of the benefit plans we offer and administer. Our strategic approach centers around 4 distinct pillars that construct an effective balance of preventive, detective, and reactive controls, and effectively strike the pressures, opportunities, and rationalizations of those intent on gaining an unjust advantage or benefit through resilient disruption and real consequences. To learn more about our approach, visit our website here.
How can you help?
Benefits fraud affects us all. You play an important role in helping us prevent benefits fraud and abuse and ultimately ensuring health care benefits and services remain accessible for years to come.
While many cases of benefits fraud and abuse are committed with purpose and intention, there are also cases where fraud happens unknowingly or with passive awareness and acceptance. It’s important to keep a watchful eye so you can recognize it and know what to do when it happens. Stay vigilant of the tell-tale signs, which commonly include feeling pressured or encouraged by friends and family members, colleagues, service providers, or patients to do one or more of the following:
- Receive or provide products or services that not required or medically necessary
- Claim or bill for products or services that were not received or provided
- Include false or misleading information on a claim form, invoice, or receipt
- Accept rewards or incentives in exchange of your policy information
Want to know how you can report suspected fraud? Visit our website here.
To learn more about fraud prevention, visit fraudisfraud.ca.