Your benefits plan helps to cover or supplement the cost of providing health and dental care benefits to you and your eligible dependants. But benefits fraud can put your benefits at risk. For example, billing or claiming for services that never occurred and falsifying frequency or description of services rendered has significant consequences for you, your service provider, and your benefits plan.
Why does this matter to you?
Benefits fraud can make the cost of providing benefits more expensive and may lead to higher premium payments and co-insurances and/or reduced coverage.
When plan members commit benefits fraud, it’s not stealing from the insurance company; it’s stealing from your plan and colleagues (i.e. other plan members). Every dollar paid out for a fraudulent claim is a dollar that is not available for legitimate health and dental care needs. Plan members who commit benefits fraud may face serious consequences, like fines and online claims submission being permanently revoked.
Your insurer (Manulife) will routinely and randomly audit benefit claims, and you may be asked to provide additional information about a claim. Be sure to keep your claim receipts for up to 12 months from the date you submit a claim. Claims proven to be fraudulent are reported to your benefits plan for review and action in accordance with your plan’s anti-fraud policy.
Claims that are deemed fraudulent will not be approved or eligible for reimbursement. To avoid paying out-of-pocket for claims, check the list of delisted providers before you book your next appointment.
You play a key role in safeguarding your plan to keep your benefits affordable, accessible, and sustainable for when you, your family and your colleagues need it.
How can you protect yourself and the plan?
Understanding your benefits and how to use them appropriately can help you safeguard yourself and the plan against potential fraud and abuse. Here’s how:
- Familiarize yourself with your benefits plan and the limits of your coverage.
- Keep your benefits plan information, card, and OTIP plan member site password in a safe place and do not share it with anyone.
- Make sure your practitioner is licensed with the appropriate regulatory board.
- Ask questions of your service providers so you understand the treatments, services, and products being prescribed to you.
- Check that the explanation of benefits (EOB) and receipts provided by your insurer contain accurate information about the services or products you received.
- Notify and reimburse your insurer if you return previously claimed items for a refund.
To help you learn how to spot benefits fraud and what steps you can take if you suspect fraudulent activities, read the frequently asked questions below.
What does benefits fraud look like?
Benefits fraud involves intentionally submitting false or misleading information to an insurance provider for financial gain [1]. It can be committed by service providers and plan members, or both working together. Sometimes, benefits fraud occurs without your consent or knowledge. Some examples include:
- Letting someone not covered by your plan use your benefits.
- Claiming/billing for health or dental services that were not received/provided.
- Submitting the same claim to multiple insurers.
- Using your benefits to buy non-eligible items (e.g. non-prescription sunglasses submitted as prescription eyeglasses).
- Falsifying procedures to receive payment for non-eligible expenses.
- Returning items after reimbursement.
How does benefits abuse differ from benefits fraud?
Benefits abuse means taking advantage of the contract’s provisions and/or health professional guidelines for personal gain. While misuse is not against the law, it is unethical and has a negative impact on your plan. Some examples include:
- Using benefits up to the specific maximums when medically unnecessary.
- Providing medically unnecessary treatments.
- Offering incentives such as free gifts to encourage maximum use of benefits.
- Referring patients unnecessarily.
What should I do if I suspect benefits fraud?
Benefits fraud affects everyone, and it’s our shared responsibility to report it 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.
Safeguarding your benefits by keeping an eye out for fraud will help to keep your benefits affordable, accessible and sustainable for many years to come.
[1] https://fraudisfraud.ca. Canadian Life and Health Insurance Association Inc.