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.
Our strategic approach
We have a zero-tolerance policy toward benefits fraud and abuse and are 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.
Prevention & awareness
Awareness and education are critical to stopping benefits fraud and abuse before it starts, and ensuring our employees, plan members, plan sponsors, health care providers, and other important partners are educated on the impacts and consequences, as well as how it can be avoided, is one of our top priorities. We also incorporate countless system, plan design, and claims processing controls to shut down opportunities before they occur and further leverage joint industry and partner collaboration for collective action, investment, and best practices on common anti-fraud efforts.
Monitoring & detection
Our dedicated Claims Integrity Specialists monitor and respond to various information sources for detecting irregular or suspicious activities, including tracking unusual claims patterns and data observations, routine and targeted claims audits, tips reported from concerned members of the public, and referrals from our diligent claims examiners. We are continuously investing in new tools and technologies to stay ahead of today’s increasingly sophisticated schemes in the new digital and online world, to flag even more violations, focus our efforts on the greatest risks, and reduce false positives.
Investigation & resources
All suspected instances of benefits fraud and abuse are pursued and investigated by our skilled Claims Integrity Specialists, who are members of the Association of Certified Fraud Examiners. Using their professional knowledge and experience, they leverage various tools and best practices to gather evidence, collect statements, and write detailed reports of their findings. Where an investigation leads to an adverse conclusion, recommendations are prepared and considered, including whether to manage our response internally or refer to proper authorities. In all cases, we apply lessons learned to improve our strategic controls.
Resolution & recoveries
When benefits fraud or abuse is confirmed, we act to hold involved parties accountable and ensure proper corrective actions are taken. Our responses may include reporting a plan member to their employer, suspending or terminating a plan member’s benefits or a provider’s billing agreement, delisting specific providers or clinics, filing complaints with regulatory bodies or professional associations, or even referring matters to law enforcement. We also pursue various means to recover funds, including issuing repayment requests, engaging of collection agencies, and commencing civil litigation when needed.
How you can help
Benefits fraud and abuse impacts us all – whether you are a plan member, plan sponsor, health care provider, or other important partner, you play an important role in helping us prevent benefits fraud and abuse and ultimately ensuring valuable 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, occurrences may also happen unknowingly or with passive awareness and acceptance. It is important we can all recognize it and know what to do when we spot it or become linked to such activities. 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
Report suspected fraud
If you suspect any potential benefits fraud or plan abuse, please report your concerns to us by emailing email@example.com – in all cases, your identity and report will remain confidential. Or, if you wish to report your concerns anonymously, please call us toll-free at 1-877-522-5477.
How to prevent fraud
There are many ways you can protect your benefits plan or health care practice from potential fraud or abuse.
Protecting your benefits from misuse often starts with understanding your benefits, and we recommend you read your member policy or benefits booklet, paying special attention to the covered benefits, their maximums and limitations, and plan exclusions. It is also important you understand the products or services you receive from health care providers, seek services from licensed professionals, and know what you are being charged for or a provider may be billing to us on your behalf. These actions will help you spot anything that seems unusual and help ensure your claims contain accurate information about the products and services received.
Protecting the benefits you offer your employees not only signals your commitment to keeping their coverage valuable and affordable, but it also reveals your care for their lifelong health and wellbeing. Smart plan designs are a simple way to set limits on commonly abused services, while educating your employees on what constitutes benefits fraud, how it impacts your organization, and the real consequences it can have on them, is a great way to spread awareness and deter it before it is considered or carried out. These actions will help charge your employees with the same sense of duty to report suspicious activity and to use their plan responsibly.
Protecting your practice, licence, and patient trust begins with understanding what is acceptable and what is not. Refusing to inflate claims and charges, misrepresent products and services, switch claimants, or extend incentives are all good practice. To avoid running foul of claim submission standards, and possible delisting, it’s important you operate within your standards of professional practice and ethics, and abide by important record keeping criteria, like billing or issuing accurate claims, receipts, or invoices with the correct patient name, purchase or service date, product or service description, provider name and location, and amount charged.