01 Nov Health and Dental Benefits Fraud – What You Need To Know
Heath and Dental Benefits fraud occurs when someone deliberately submits false or misleading information to an insurance provider, for the purpose of financial gain. There are many ways in which someone could commit benefits fraud, such as submitting a false claim, forging receipts, sharing benefits with others or misrepresenting services.
Benefits fraud can be committed by a plan member, the health care provider or through collusion. All acts of fraud are illegal which can lead to a criminal record, fines and even jail time.
While insurance fraud is often thought of as a ‘hidden crime,’ the costs are very visible. Benefits fraud and abuse cost the Canadian health insurance industry up to $3.6 billion each year. This leads to increased costs that are passed on from the insurance company to employers and ultimately to employees, costing Canadians hundreds of millions of dollars each year. When employers can no longer afford the additional costs brought on by benefits fraud and abuse, this results in the reduction or elimination of benefit plans.
Benefits fraud and claims abuse are serious offences, it is theft from your benefits plan. You wouldn’t pay a credit card bill for something you did not buy, and the same logic applies to your benefit plan – no one should pay for a false claim.
Now that you know the seriousness of fraud and claims abuse, be involved in the solution and do your part to prevent it:
Review your benefit booklet to understand your coverage.
- Keep your benefits information confidential – no healthcare provider or dentist needs to have a copy of your benefit booklet to provide you or your family with required services or treatment.
- Make sure your healthcare provider has legitimate credentials and is licensed to practice in your province.
- Always check your receipts and Explanation of Benefits – make sure you are only billed for the services you received. Ask for clarification if the receipt is not clear.
- Submit claims online –along with being convenient, there are many checks and balances built in.
- You are responsible for ensuring that claim information submitted under your name is correct.
- Never pre-sign blank claim forms – if you do, you will be held liable for anything that is submitted.
- If you are asked to participate in a claim audit, understand that this is a regular part of the claim submission process and is one of the many safeguards that are in place to protect plans from fraud.
- Report suspicious activity to your employer or JRP Employee Benefit Solutions.
What is your Benefits Advisor doing to protect YOUR plan, to assist you in detecting questionable activity and trends or possible benefits plan fraud? Misleading and fraudulent claims that are run through a group benefit plan will ultimately inflate the cost of your plan. This will clearly result in having to pay more because when your claims increase, you will proportionately pay more in premium. Today’s claims become tomorrow’s premiums.
JRP provides a Claims Auditing Intervention Service that empowers us to proactively understand and manage your plan. We evaluate claims reporting on a monthly basis and report our in-depth analysis to you formally every quarter. Our customized approach ensures that we are always monitoring the pulse of your plan.
JRP’s Claims Auditing Intervention Service includes:
- Identifying cost drivers and forecasting future benefit costs.
- Providing advice on potential cost mitigation strategies and coverage alternatives.
- Recognizing emerging trends and suspect activities that require additional exploration.
- Instigation of audits and claim investigations with providers and claims adjudicators when required.
- Conducting Drug Utilization Reviews that allow us to identify available Pharmaceutical Subsidy and Patient Assistance Programs.
- Determining available Provincial Healthcare Coverage and Co-ordination opportunities.
- Determining communication strategies that will educate your members so they become informed consumers who know how to protect themselves from fraud.
Your benefits plan provides protection and financial security to you and your family and is an important part of your overall compensation package. Protect it.