How Fraud Happens
Fraud comes in many different guises.
Service providers, such as dentists, physiotherapists, massage therapists and chiropractors, or their employees, may submit claims without your knowledge for services they never provided to you.
Plan members can also commit fraud by submitting false claims.
Participants and service providers may collude in submitting claims for covered products or services, while the products or services provided are not. Here are some examples:
Obtain a spa treatment, such as a facial treatment, and submit an invoice for a therapeutic massage
Obtain athletic or dress shoes and submit an invoice for orthotics
Obtain designer sunglasses and present an invoice for prescription glasses
Receive a teeth whitening treatment or cosmetic service and give a bill for regular dental care
Third parties may also commit fraud, usually by making unauthorized use of a service provider’s name.
You can help protect your plan.
Here’s how you can protect yourself from the dangers of group benefits fraud:
Protect the confidentiality of your group benefits information. This prevents others from fraudulently submitting claims on your behalf.
Submit your claims online whenever possible. Submitting claims online and automatically depositing benefits reduces the likelihood of fraud, and it’s faster than paper. Be sure to review any emails your service provider sends you about recent claims.
Check your receipts. Make sure your tickets are accurate and reflect the services you received. Make sure that the name on the receipt is that of the service provider who provided you with the services. Don’t be afraid to ask the service provider for clarification.
Do not sign claim forms in advance. Only sign one complete claim form at a time and never sign blank forms. Make sure you always understand what is presented for your account.
Report any suspicious activity. If an action or request from a supplier of medical services or equipment seems suspicious to you (for example, an activity that provides you with no or little benefit, but which would maximize the payments made to this supplier, taking into account your coverage), report it to your employer or benefits provider.
To prevent fraud from impacting your health care coverage and your wallet, do your part and be vigilant.
