What we do:

In active pursuit of unjust claims to protect our group policyholders

Tip Implement preventative strategies with internal and external awareness tactics. We engage Advisors, Plan Sponsors and Plan Members in trending fraudulent activities so they are aware of their role in fraud reporting and management. We all have a part to play in fraud prevention; it starts with awareness and ends with justice.
Track Investigates suspicious activity and collects evidence with a team of resources. We are a member of the Canadian Health Care Anti-fraud Association (CHCAA) and we work collaboratively with Canadian Life and Health Insurance Association (CLHIA), the Insurance Bureau of Canada (IBC), Provincial Police Forces, medical consultants and associations.
Action Take recovery action against fraudulent activity. After the Fraud Squad has staked out the perpetrator, it's time for action. Our investigative services team packs a force to be reckoned with. Their goal is clear – recover all the fraudulent funds.


“Like theft, we can all be victims of fraud. Our team reduces the risk of unnecessary
costs to our group benefits plans through preventative and recovery strategies.”
Senior Fraudulent Claims Consultant


 

Prevention is our standard.
Receipts are required for
EVERY claim submission
100% of the time.

Recovery is our goal.
We recovered more than $1M 
in 2015 and $11M+ since
inception in 1999.

Trust in our experience.
Over 15 years of investigating
goes a long way to protecting
group policies.

 


Fraudulent trend stories

The case of… Reception deception
A receptionist at a physiotherapy clinic was caught creating phony receipts for her family. The fraud squad launched a full investigation with the clinic, and the receptionist confessed.

RECOVERED: 100%
CONSEQUENCE: Job loss and permanent record with provincial authorities.

The case of… Riding the ambulance train
A plan member claimed he had ridden an ambulance on several occasions. After investigating with provincial health care, the claimant confessed to committing fraud.

RECOVERED: Payment arrangements to recover 100%
CONSEQUENCE: Permanent record with provincial authorities.

The case of… Phony psychology
A claims adjudicator noticed alterations made to receipts. The fraud squad contacted the service provider and confirmed the patient had not seen the Doctor on the claimed dates of service.

RECOVERED: 100%
CONSEQUENCE: Insured was informed that all future claims for this family will be monitored to insure validity.

 

 

 

 

 

 

 

Fraudster_2


Defining fraud and misuse of benefits

  • Service substitution is fraud. Example: Submitting a claim for acupuncture when the service you received was massage therapy. Regardless if your plan has massage therapy coverage, it's still fraud.
  • When a service provider submits claims for treatments you did not receive – that’s fraud. It happens quite often. Check receipts; be aware of what is being charged to your plan and your employer.
  • Seeking treatments that are not medically necessary is misuse of benefits. Benefits are there to support health needs, not wants. It’s your responsibility to your employer to use your benefits properly, when medically necessary.

Our roles in fraud prevention

Contact the Fraud Squad to report suspicious or fraudulent activity anonymously 1.800.265.8899

Plan member

  • Keep it confidential. Protect your benefit policy information like your PIN number
  • When asked about your benefit plan (even from a service provider), keep coverage details and maximums private. Your treatment should be based on medical needs, not your coverage
  • Validate the credentials of a service provider before seeking treatment
  • Check your receipts. Be sure that you received the treatment your plan was charged
  • Never leave a signed blank claim form at the front desk, service providers can be fraudulent too

Equitable Life

  • Enforce mandatory receipts with every claim submission
  • Drive fraud prevention awareness
  • Audit, audit, audit
  • Investigate suspicious claims activity
  • Monitor fraudulent trends in the industry
  • Help protect group policies from fraudulent claims
  • Increase benefit plan sustainability by preventing and investigating fraud
  • Recover as much as possible, whenever possible

“Most fraudsters don’t realize that fraud against the benefit plan is fraud against their employer.”
Fraudulent Claims Consultant