March is Fraud Prevention Month

March 1, 2023

Benefits fraud costs all Canadians, due to a result in higher premiums. It can also result in serious consequences. 

What is benefits fraud?

Benefits fraud happens when a person knowingly submits false or inaccurate information on a claim for health or dental coverage.

What are the consequences of benefits fraud?

  1. You could lose your benefits. Your insurance provider could increase your premiums or your employer could reduce coverage. In addition to having to pay the money back, you could lose your benefits completely.
  2. You could lose your job. Stealing from your employer is a serious offence, and many employers have a zero-tolerance policy for benefits fraud. Being fired for benefits fraud could make it hard to get another job.
  3. There could be jail time. A fraud conviction results in a permanent criminal record. Even if you avoid jail, having a criminal record could make it very difficult for you to get a job or travel.


How to recognize benefits fraud

  1.  Watch out for providers who try to use your plan member information (i.e., usernames, passwords and other personal information) to charge for products and services you never received.
  2.  Your explanation of benefits contains products or services not obtained by you or your eligible dependents. Always review your explanation of benefits and report any discrepancies to your employer.
  3.  Your provider requests (supposedly for your convenience) that you sign a blank claim form. By having a signed healthcare or dental claim form, it is much easier to commit fraud in your name. 
  4. Claiming for products and services not eligible as a benefit under your plan using benefit codes that are eligible for reimbursement (e.g., a spa day treatment submitted as massage therapy, designer sunglasses submitted as prescription glasses).           
  5.  You are offered cash or other incentives in exchange for your policy and certificate numbers. Report anyone asking for this type of information. 
  6.  Be on guard if your health care provider appears more concerned about obtaining a list of your covered benefits and the associated plan maximums than they are about providing you with the right product or service.
  7.  With offers of incentives remember the “too good to be true” rule. Somebody is paying for those free services perhaps through hidden fees or built-in costs.
  8.  Beware of providers that offer to bill a service as something other than the service received as a way to work around eligibility requirements or plan maximums.
  9.  Shop around and ask questions to ensure the health care provider has the appropriate credentials for the services you are receiving.
  10.  When paying for products/services, be wary of providers who ask if you have insurance. You or your plan sponsor may end up paying more than someone who does not have insurance.

Source: Canadian Life & Health Insurance Association Inc. 

How do I protect myself from benefits fraud? 

  1. Protect your personal information which includes your benefits plan access information. 
  2. Don't let someone else borrow your card to obtain services or products.   
  3. Ensure your receipts are correct and reflect the service or treatment you received.
  4. Check your explanation of benefits (EOB) provided by your insurer for services considered under your benefits plan to ensure that it reflects only those services or products obtained by you or your eligible dependents.
  5. Don't sign your name to blank claim forms.       
  6. Understand your coverage and the limits that apply under your plan.      
  7. Ask questions. Don’t hesitate to question the treatment or service being prescribed or given to you.         
  8. Remember to keep your receipts. You may be asked to submit them in support of your claim.     
  9. Alert your insurer of any providers who routinely waive your co-payment or deductible. 
  10. Report it. If you suspect potential plan abuse or fraud, report it to your insurance company.

Source:  Canadian Life & Health Insurance Association Inc.