Protect your plan – preventing benefits fraud

March is Fraud Prevention Month.

For most people, health and dental benefits fraud is not something that comes to mind often. But benefits fraud is a real problem - one that can have both significant financial implications and criminal consequences.

It’s important to understand what benefits fraud is, its impacts, and how you can help prevent it.

What is benefits fraud?

“Benefits fraud is the intent to obtain reimbursement for claimable goods or services that were neither received nor provided,” says Gil Johnston, Supervisor of the Investigation Services Unit at Manitoba Blue Cross.

According to the Canadian Health and Life Insurance Association (CHLIA), benefits fraud can happen when you:

• let a friend use your benefits because they reached their maximum
• increase the amount of a claim to cover any part of the cost not covered by insurance
• claim under a dependent’s coverage when you received the treatment or service
• claim prescription drugs on behalf of other people who are not covered under your plan
• purchase something that isn’t covered under your plan and claiming it under a benefit you do have (e.g., buying non-prescription sunglasses and submitting the claim as prescription eyeglasses)
• purchase trip-cancellation insurance after finding out you cannot go on a scheduled trip
• submit a full claim to more than one insurer to double your reimbursement

The consequences of benefits fraud

At the end of the day, benefits fraud is stealing. And as Johnston reminds us, “insurance fraud is not a victimless crime. As the costs rise due to the fraudulent claims, that cost is then placed on the Plan Sponsor (the company or employer) who may decide to modify or limit some benefit coverage. They may even cancel the coverage altogether.”

People who engage in insurance fraud or abuse can face serious consequences, potentially losing their coverage and their job. They may even face investigation by local authorities and risk possible jail time.

Protect your plan

Even when your plan is used properly, you can still become an unwitting participant in benefits fraud. Protect yourself and your plan by following these tips:

• Never sign blank claim forms for providers. By signing forms, you are confirming your authorization and consent as well as verifying the accuracy of the information in the claim being submitted on your behalf.
• Verify that your provider is approved by and registered with Manitoba Blue Cross prior to obtaining services.
• Ensure that the benefits you are claiming are the goods and services that you received.
• Treat your Manitoba Blue Cross number like a social insurance number – do not let anyone else use it.
• Ensure that all receipts submitted reflect the accurate dates and payments and that services have been provided in full before submitting a claim.
• Report any incidences of providers offering to alter claim information to meet your claiming requirements.
• Report any incidences of providers recommending services to maximize your benefit payments.
• Notify Manitoba Blue Cross if you return an item that had been previously processed under your plan.
• Keep records of appointments and treatment dates and receipts for co-payments.
• Review your Explanation of Benefits for claims where the provider submits directly to Manitoba Blue Cross on your behalf.

Johnston and the Investigation Services Unit team at Manitoba Blue Cross work proactively to prevent fraud and abuse by building an anti-fraud culture through education, analytics, controls and efficiencies.  

He strongly suggests reporting benefits fraud if you suspect it is happening. The simple process allows you to provide an anonymous email tip directly to the individual insurer or to a larger list of insurance providers across Canada.

To anonymously report fraud to Manitoba Blue Cross, call 204.789.8805 or toll-free 1.877.998.8477 or email protectyourplan@mb.bluecross.ca.

To learn more about benefits fraud, visit: https://fraudisfraud.ca.

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