Why fraud matters...

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Did you know it’s estimated that more than $5 billion is lost each year in Canada to health care benefits fraud and abuse?

March was Fraud Prevention Month, so we're taking the opportunity to tell you about Sun Life’s approach to preventing, detecting and deterring benefits fraud and abuse. We’ll also highlight ways that you and your plan members can take action to prevent fraud and abuse.

Shining a light on fraud and abuse

Your group benefits plan is an important investment. In an environment of economic uncertainty and escalating health care costs, you cannot afford to see your benefits investment eroded by improper claims and fraudulent activity. The resulting financial loss can lead to significant additional costs to you through increased premiums and claims – and ultimately to your plan members as it impacts the type of coverage you can provide to them. Along with Sun Life, you and your members play a vital role in helping to keep your plan well protected. As your benefits provider, we’ll lead the way by shining a revealing light on the road ahead.

What is fraud?

Benefits fraud is an intentional deception or misrepresentation by an individual or entity in respect of a claim which results in payment for an ineligible benefit under the benefit plan.

What is abuse?

Benefits abuse occurs from practices that, although not usually considered fraudulent, are inconsistent with accepted, sound, medical, dental, or business practices. Examples of abuse include over treatment, excessive billing and billing for services which are not medically necessary.

All in a day's work - protecting your benefits plan

We take our job and your business seriously. As one of the industry leaders, Sun Life is actively on the job every day protecting your group benefits plan. We take a proactive, serious approach that combines the use of powerful technologies with skilled experts in fraud and abuse management. Here are a few examples of the controls and processes we deploy every day to prevent, detect and deter fraud and abuse: 

  • Strong internal controls to minimize risk of staff improprieties – Sun Life staff is restricted to performing only authorized activities (e.g. controlled system access, restrictions to specific transaction/contracts, transaction amount limits)
  • Identify and take action on red flags – We invest in training our claims examiners and call centre staff to recognize potential fraud or abuse indicators and uncover suspicious claims and inquiries. These include altered receipts, members pressuring call centre staff to pay quickly without complete documentation. We refer these situations to our Investigative Services Unit (ISU).
  • Quality control protocols that monitor for results – We are strict about the quality control checkpoints necessary for optimal results. Our quality assurance processes monitor the quality of our claims examiners’ and call centre staffs’ work. We verify claim accuracy and appropriate identification of red flags.
  • We maintain a Hospital Watch List – We carefully monitor hospitals who appear to have a history of billing practices that may not be appropriate and conduct prepayment audits on selected incoming claim from them to ensure their submission aligns with your plan provisions’ intent.
  • We own sophisticated technology – We use the advantages our industry leading technology brings us to run claim trend analysis reports to identify unusual patterns. In selected cases, we compare provider billing practices relevant to peers. And, when major deviations or unusual patterns are detected, we aggressively pursue the offenders to recover funds and work to change future billing behaviour.
  • ISU experts transform technology info into insights that lead to results – This specialized team transforms health and dental information from claims examiners, customer service representatives, technology applications and deploy their experience, instincts and solid investigative skills to detect and deter common fraud activities as well as new and inventive fraud and abuse schemes as they evolve.
  • Our fraud team takes action – Beyond detecting fraud and abuse – the team is trained to take appropriate action when improper claims or other fraud and abuse occur, including; obtaining repayment, removing plan member online access for claim submission, pursuing criminal charges with police agencies and pursuing disciplinary action with service providers’ regulatory bodies, where appropriate.
  • The sentinel effect as a power tool – Once fraud and abuse offenders know we are watching them and shining our light on their practices – they usually change their behaviour and they may circulate this information to other potential offenders.

Partnering for industry leadership

Sun Life is committed to furthering education and communication to raise awareness of and to prevent health care benefits fraud in the workplace. We participate on the board of directors of the Canadian Health Care Anti-Fraud Association (CHCAA), one of one of Canada’s leading anti-fraud organizations.

Through active involvement in the CHCAA, Sun Life is at the forefront ready to rapidly adopt emerging developments and to continuously evolve and strengthen our fraud management capabilities and practices. In fact, in March, in collaboration with the CHCAA, events were held in four key Sun Life locations for internal audiences to increase awareness and to continue to educate our own people about fraud and abuse management.

Protection starts with you

This is where you come in – As a plan sponsor, you have good reason to want to preserve your valuable group benefits plan. In fact, there are many ways that you can help ensure your group plan is thoroughly protected against fraud and abuse. Here’s what you can do:

  • Review your plan design with your advisor or account executive to find areas that may unnecessarily leave you exposed to fraud and abuse.
  • Ensure reasonable coverage limits and benefit maximums are in place.
  • Use deductibles and co-payment features to keep plan members financially involved with incentive to actively manage their benefits expenditures.
  • Consider a Health Spending Account to offer more flexibility while containing expenses.
  • Establish a health benefits policy or code of ethics for your members that includes a statement about the important role they play in controlling their benefits costs through proper use and the serious consequences to them if it is discovered they have committed fraud.
  • Educate and support your members about the roles they should play in helping prevent fraud and abuse so they understand the impact they have on their own benefits coverage.
  • Encourage your members to speak to their health care providers about services or products they receive. Are the services necessary? What do they cost? Would the same treatment be used if they didn’t have benefits coverage?
  • Encourage members to determine their providers’ qualifications and ensure that they are appropriate for the treatments, products and services being obtained as well as satisfying plan eligibility requirements.
  • Take fraud and abuse seriously. Do not allow your plan members, service providers or others to undermine your benefits plan. Encourage members to contact us on our toll free line at 1-800-361-6212 if they suspect fraud or abuse is occurring.

We are also attaching tips you can share with your plan members on actions they can take to help prevent fraud and abuse.

Over the coming year, watch for more communication and education material about fraud and abuse and specifically how Sun Life’s fraud management capabilities help to safeguard your investment in your benefits plan every day.

Questions?

Please contact your Sun Life Financial group representative.