How you can help prevent claims fraud

Approximately two to 10% of every health-care dollar is lost to fraud. Insurance fraud in Canada is growing in the group benefits landscape and becoming more prevalent.

We’re serious about detecting and preventing health and dental benefits fraud. Our goal is to ensure your benefits plan is sustainable, cost effective and supports the well-being of your plan members and their families.

What are we doing?

Fraudulent schemes can be elaborate and evolve constantly. While suspicious behaviour might not result in a denied claim, it could cause plan member claims history and pattern to be reviewed.

Our trained staff is dedicated to detecting fraudulent claims and preventing future losses. We’re always enhancing our existing programs and developing new methods to identify unusual claim patterns. To do so, we:

• Analyze claims patterns and benefit usage by group
• Request additional supporting documentation on suspicious claims from the plan member and verification from the practitioner
• Maintain a provider Watch List
• Participate in The Canadian Life and Health Insurance Association (CLHIA) Healthcare Anti-Fraud Committee

Fraud-resistant contract wording

Some contract wording around medical necessity helps us protect your plan from fraud. All our group insurance extended health plans contain this clause:

All Allowable Expenses covered under the Extended health-care Benefit provision must represent Reasonable and Customary Treatment of the Covered Person’s Medically Diagnosed Condition.

This is different from a physician’s referral, which not all plans contain. Physicians’ referrals are used when the claimant requires a physician prescription or referral for paramedical services such as massage or physio. A copy of the referral must accompany the claim.

The claim form wording also helps. When claimants sign the bottom of the form, it authorizes us to ask for any medical or relevant personal information to investigate and confirm that the expenses represent reasonable and customary treatment of the covered person's medically diagnosed condition.

Most of the increase in fraud we’re seeing is in medical equipment such as braces, TENS, compression stockings and orthotics. Paramedical practitioners are also among the top five areas of increased fraud, including massage, chiropractic, osteopaths, acupuncture and physiotherapy.

How you can help prevent fraud

We all have a role in creating an anti-fraud culture and supporting each other in prevention efforts. As a plan sponsor, you can:

• Support plan member education.
• Treat health and dental care fraud as a serious matter.
• Use co-payment plans to keep the plan member involved.
• Select plan design options that help prevent fraud, including setting limits on commonly abused services and maximums to reduce overall risk.

You can also educate your plan members on these simple ways to help prevent fraud:

• Ensure their health-care providers are licensed and receipts are correct.
• Refuse to let anyone borrow their card to obtain services or products.
• Keep their benefit cards and information safe.
• Never sign a blank claims form and report providers who request this.

If you suspect fraudulent or inappropriate behaviour, report it immediately to our Client Service Centre at 1-800-667-8164 or contact the Canadian Life and Health Insurance Association.