Misuse of benefits impacts us all
Your RTIP/ARM benefits plan is intended to provide you and your loved ones with the health, dental and travel insurance needed for everyday life.
Each RTIP/ARM plan has a monthly premium that is calculated based on annual factors like the number of claims, reimbursements, types of benefits coverage and plan usage. These factors help to determine the affordability and premiums for the plan from year to year. For instance, if dental benefits were heavily used by members in a year, the monthly premium may increase the following year to sustain that coverage level.
Benefits fraud and abuse can also have a big impact on a plan’s bottom line. It has a direct impact on the ability of 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 RTIP/ARM 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, 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 your plan’s coverage or a 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 and/or plan members. Sometimes benefits fraud or abuse can happen without your consent or knowledge. With this in mind, there are many things that you can do 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 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 OTIP.
- Report odd or suspicious behaviour or practices to OTIP Benefits Services.
- Be enticed by cash rebates or free 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 OTIP, and possible charges may apply.
If you have suspected benefits fraud or abuse, please call Manulife (the insurer) at 1-877-481-9171.
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