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How to help prevent claims fraud

Did you know that approximately 2-10% of every health care dollar is lost to fraud? Insurance fraud in Canada is growing in the group benefits landscape and becoming more prevalent.

At The Co-operators, we’re serious about the detection and prevention of health and dental benefits fraud. Our goal is to ensure that the well-being of plan members and their families is supported by a plan that’s sustainable and cost effective.

What are we doing?

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

Our trained staff is dedicated to detecting fraudulent claims and preventing future losses. We’re continuously enhancing our existing programs and developing new methods to identify unusual claim patterns. Some of the ways we do this include:

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

What can you do?

We all have a role in creating an anti-fraud culture and must support each other in prevention efforts. Talk to your plan sponsors to make sure they:

  • 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

Additionally, encourage plan sponsors to educate 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.