March is Fraud Prevention Month in Canada, and we are kicking it off with the latest in group benefits fraud news and what you can do to avoid it. Fraud is a serious industry-wide issue and prevention is key.
Benefits fraud happens when information is intentionally falsified during the claims process for financial or personal gain. It can happen by a service provider, plan member, or plan members and service providers working together. The most common type of benefits fraud are collusion schemes and substitutions for services and products that are not covered with those that are. According to Manulife and Sunlife, the most popular substitutions are:
- Facial or spa services instead of therapeutic massage
- Running shoes instead of orthotics
- Personal training instead of physiotherapy.
Benefits fraud has serious consequences that include increased premiums, repayment, delistment of service providers, job loss, suspension, criminal charges and even jail time! The more plan members and service providers know about the negative impacts of benefits fraud and abuse, the better equipped – and more likely – they’ll be able to help prevent it.
Here are a list of do’s and don’ts to do your part in the fight against benefit fraud.
- Use benefits plan for its intended purpose – expenses incurred are for medically reasonable and necessary treatment.
- Make sure treatments being provided are explained to plan members and receipts accurately reflect the service provided and service provider that provided that service.
- Notify and reimburse the insurance carrier, if previously claimed items are returned for a refund.
- Review Explanation of Benefits (EOB) for accuracy and report any concerns or billing discrepancies to the insurer.
- Only obtain plan benefits numbers for clients that you have authorized to submit electronic claims on their behalf.
- Offer cash rebates, free shoes or other products.
- Ask clients to sign blank claim forms.
- Submit claims prior to providing the medical treatment, product or service.
- Provide receipts for services or supplies that have not received.
- Ask or obtain login user names or passwords to the secure member site.
Group benefits insurers have specialized teams, data analytics, and fraud-identifying technology – all which work in unison to monitor claims and identify red flags, anomalies, patterns, and even predictive modelling for outliers. Some of the red flags include invoices with a modified date, entire families claiming similar supplies or services, a history of frequent or high-value claims, many plan members in one group using the same healthcare provider or trends, a plan member consulting many healthcare providers, vague or evasive answers from plan members and healthcare providers when questioned.
To learn more about group benefits fraud prevention, check out Fraud-Fraud founded by Canadian Life and Health Insurance Association with the support of its member companies.
As always, keep checking our blog for the latest in industry and technology news!