HEALTH BENEFITS
Protect Yourself From Benefits Fraud
Gary Sawatzky | Chief Operating Officer, ARTA
Group benefits fraud has proven to be a very lucrative way for certain unscrupulous individuals to take advantage of people and group benefit plans in Canada.
This form of fraud affects insurers and plan sponsors alike, driving up costs and threatening the sustainability of benefit programs like ARTA’ s. It’ s especially important to ensure fraudulent actions are detected and abolished given that ARTA’ s members pay 100 % of the plan premiums, which are directly affected by claims paid by the plan.
Group benefits fraud occurs when covered members or service providers intentionally submit false, exaggerated, or misleading claims to a group benefits plan for financial gain.
Members commit fraud by
• submitting claims for services never rendered.
• altering receipts to increase the submitted claim amount.
• benefit card swapping or using someone else’ s coverage.
• falsifying eligibility to get coverage under a plan.
• forging or stealing prescriptions.
• submitting a full claim for the same service to multiple providers.
• abusing narcotics by receiving prescriptions for the same medication from multiple doctors or pharmacies.
• returning items after being reimbursed.
Service providers commit fraud by
• billing for treatments, products, or services that were never provided.
• providing medically unnecessary treatments, products, or services.
• providing false or altered invoices.
• falsifying procedures performed or goods provided to receive payment for non-eligible expenses.
• misrepresenting themselves as licensed practitioners.
• billing for higher-priced services or excessive use of time.
The industry has taken it upon itself to try to reduce the amount of fraud in the system. In 2022 the Canadian Life and Health Insurance Association( CLHIA) launched an initiative through which CLHIA members( insurance providers) share aggregate anonymized claims data for review using artificial intelligence to help determine if claims are fraudulent. For example, their system can determine if a particular provider had an“ impossible day” where they claimed three hours of services to ten different providers. Before artificial intelligence, it was not possible to find these types of fraudulent claims simply because of the vast amount of data. However, working with covered members is still the best way to determine if a provider is acting fraudulently.
8 | arta. net IMAGINE