What is benefits fraud and abuse?
Benefits fraud and abuse refers to the either the misuse or overuse of a benefits plan, most commonly for the purposes of financial gain – this might involve someone using a plan in a way that is contrary to the intended purpose of a benefit, or possibly seeking reimbursement for a good or service they are not entitled to. It can take many forms, ranging from improper billings, excessive charges, billed services and supplies not supported by an evidenced medical need, to deceitful claims for products or treatments that were neither received nor provided.
These actions may be carried out by plan members, their covered dependents, or even trusted health care service 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.
And while most plan members, service providers, and medical suppliers are honest and proper in their dealings with us, 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 family members, peers, or service providers. Whatever the justification, these actions are simply wrong, unethical, and often outright illegal, with far-reaching consequences often not considered.
Did you know?
- Fraudulent claims and plan misuse impact more than just your insurance service provider. These actions impact everyone, leading to higher benefit payouts and increased costs for a plan overall, often resulting in higher premiums for plan sponsors and members, reduction of benefits or coverage levels offered, or the elimination of benefits plans altogether.
- Getting caught committing benefits fraud or abuse is a serious matter. It can lead to repayment of false or excessive claims, loss of coverage for you and your covered family members, loss of employment and a damaged reputation, a criminal record or even imprisonment.
For more examples of benefits fraud and abuse and its consequences, or to find other frequently asked questions, visit www.fraudisfraud.ca.