Your Employee Life and Health Trust (ELHT) helps to cover or supplement the cost of providing health and dental benefits to you and your family.
 
But benefits fraud can put your benefits at risk.
 
The truth is, benefits fraud can lead to higher premiums, reduced coverage — or both.

It’s important for plan members to protect themselves – and their plan - from fraud. Here’s how:

• keep your benefits information private;
• submit claims online with direct deposit for faster processing;
• check claim receipts to ensure information—including provider details, service and fees—are accurate;
• familiarize yourself with your benefits plan and coverage eligibility
• monitor your claim activity; and  
• don’t sign claims forms in advance of service

When plan members commit benefits fraud, it’s not stealing from the insurance company; it is stealing from your plan and putting your benefits at risk.
 
Test your benefits fraud knowledge. Knowing how to spot benefits fraud will help you to avoid it – and protect your plan. Take our short quiz to test your knowledge.
 
Benefits fraud can also be committed by service providers.
 
Claims from providers that are deemed fraudulent will not be approved and are identified as ‘delisted’ providers by your insurer. To find out which service providers have been delisted and avoid delays in processing your claims, check out how can I view the list of delisted providers.

Don’t let others put your benefits at risk. Ask questions of your service provider.
 
Here’s what we’re doing to protect your benefits plan

Working closely with the ELHT and your insurer we help to detect suspicious claims.

All submitted claims go through advanced analytics to identify potential benefits abuse and fraudulent activity. The staff and systems used for handling claims are constantly being monitored with various detection tools including:

• Fraud recognition training
• Advanced data analytics
• System controls
• Drug management
• Specialized staff

The insurer will routinely and randomly audit benefit claims, and you may be asked to: provide additional information about a claim and/or confirm the services the health/dental provider has billed for. Be sure to keep your claim receipts for up to 12 months from the date you submit a claim.
 
Benefits fraud affects everyone, and it’s our shared responsibility to protect your plan and report fraud when we see it. If you suspect that someone you know or a service provider may be committing fraud, you can report it to your Employee Life and Health Trust, OTIP, your insurer, or anonymously.
 
Questions? We are here to help. Check your benefits booklet for benefit plan terms and coverage details. You can also contact OTIP Benefits Services at 1-866-783-6847 or send us an online note.

Related article: Learn how to spot benefits fraud – and protect your plan