How to protect yourself from benefits fraud

Odds are, your employer’s group benefits plan has been affected by fraud. According to a survey, a full 95% of Canadian plans have processed fraudulent claims.

The Canadian Life and Health Insurance Association (CLHIA) defines benefits fraud as “intentionally submitting false or misleading information to your insurance provider for the purpose of financial gain.” 

Benefits fraud can happen in a number of ways.

Service providers such as dentists, physiotherapists, massage therapists and chiropractors, or their office staff, may submit claims without your knowledge for services they never provided.

Individual plan members can also commit fraud independently by submitting false claims.

Plan members and service providers may work together to submit claims for products or services that are covered while receiving products or services that aren’t covered. This could include:

Receiving a spa treatment such as a facial and billing it as a therapeutic massage

• Billing running or dress shoes as orthotics
• Billing sunglasses as prescription eyewear
• Billing cosmetic teeth whitening as regular dental care

Third parties can also commit fraud, typically through the unauthorized use of a service provider's name.

Benefits fraud isn’t a victimless crime. The impacts are important for everyone involved, including:

1. The cost. Simply put, fraud makes the cost of providing group benefits to you more expensive because fraud can lead to higher insurance premiums, reduced coverage for you — or both. The result is that fraud adversely affects plan members who legitimately need health benefits.
2. Your health. Some healthcare service providers who commit fraud or abuse may place their patients’ health at serious risk by not providing the treatment their patients require. At the same time, if an inaccurate or false health record is created, it may affect your future ability to be insured and may be difficult to correct.
3. Your employment. If you submit fraudulent claims on your own or by working together with a service provider or other party involved in false claims, your job could be in jeopardy. In some cases, your employer may decide to discipline, suspend or even fire you.

Avoid being part of the problem. Here are some steps you can take:

1. Keep your benefits information confidential. This prevents others from fraudulently submitting claims in your name.
2. Submit claims online whenever possible. Online claims submission and direct deposit eliminates much of the possibility for fraud — and it’s faster than paper. Be sure to review all emails your benefits carrier sends you about any recent claims activities.
3. Check your receipts. Ensure your receipts are correct and reflect the service you actually received. Check that the name on the receipt matches the service provider who performed the service. Don’t be afraid to ask your service provider for clarification.
4. Don’t sign claims forms in advance. Sign one completed claim form at a time and never sign blank forms. Always understand what is being submitted on your behalf.
5. Report suspicious activity. If you suspect any activity or request from a service provider or medical equipment supplier — such as actions that provide little or no benefit to you but would maximize payments to that provider or supplier based on your coverage — let your employer or benefits carrier know.