Helping to prevent benefits fraud
Your group benefits plan is provided to you by an Employee Life and Health Trust (ELHT), which was established for the sole purpose of providing benefits to you and your family. The ELHT is required to ensure that the benefits plan is managed on a sustainable and efficient basis. The trust is funded by monies negotiated by your union or association.
The amount of benefits coverage your plan can provide is directly related to the cost of claims paid by the trust. Benefits fraud and abuse can have a big impact on this bottom line, as it has a direct impact on the ability for your plan to provide optimum coverage amounts, lower premium costs and allow for overall plan sustainability. While some consider benefits fraud a victimless crime, in reality it impacts every member of the group benefits plan.
Benefits fraud vs. abuse
Recognizing benefits fraud and benefits abuse is one of the most important steps you can take in helping to prevent it.
Fraud is the intentional submission of false or misleading information for the purpose of financial gain. Fraud is a crime, and those who are convicted face serious consequences, including potential job loss, criminal conviction, jail time and fines.
Some common examples of provider/plan member fraud include:
- Falsifying procedures to receive payment for expenses that are not eligible.
- Providing invoices that are changed.
- Billing for services that haven’t been provided.
- Returning items after reimbursement.
- Submitting forged or stolen prescriptions.
- Submitting claims from health-care clinics that don’t exist.
Abuse is taking advantage of the contract’s provisions and/or the health professional’s guidelines for personal gain. This includes overuse of services, excessive billing and providing treatment when there is no proven medical need. While misuse is not against the law, it is unethical and can have a big impact on a group benefits plan.
Some common examples of provider/plan member abuse include:
- Providing medically unnecessary treatments.
- Offering incentives such as free gifts to encourage maximum use of benefits.
- Referring patients unnecessarily.
- Using benefits up to the specific maximums where applicable, even if the products and services are not medically necessary.
- Visiting multiple doctors and/or pharmacies to get narcotics.
How you can help
Fraud and abuse can be committed by service providers, plan members, or both working together. Sometimes benefits fraud or abuse can happen without the plan members consent or knowledge. With this in mind, there are many things that you can do as a plan member to help protect your plan and yourself from benefits fraud and abuse.
- Use your benefits plan for its intended purpose – coverage for eligible expenses incurred for the medically-necessary treatment of illness or injury.
- Make sure your practitioner is licensed with the appropriate regulatory board.
- Make sure you understand the treatments you are receiving and your receipts accurately reflect the service you have received.
- Notify and reimburse Manulife, the insurance carrier, if you return previously claimed items for a refund.
- Review your Explanation of Benefits (EOB) for accuracy and report any concerns or billing discrepancies to Manulife.
- Report odd or suspicious behaviour or practices to OTIP Benefits Services.
- Be enticed by cash rebates, free shoes or other products.
- Sign blank claim forms. Be sure to report health-service providers who ask you to sign them.
- Submit a claim prior to receiving the medical treatment, product or service.
- Accept receipts for services or supplies you have not received.
- Share your benefits plan numbers with anyone other than your eligible dependants or service providers you have authorized to submit electronic claims on your behalf.
- Share or give anyone your password to your OTIP secure member site.
Every dollar paid out as a result of a fraudulent claim is one more dollar that is not available for legitimate health-care needs. Any claim suspected to be fraudulent is thoroughly investigated by Manulife, and claims proven to be fraudulent are reported to the ELHT for review and action in accordance to the trust’s anti-fraud policy.