Know the facts about group benefits fraud so you can recognize it, refuse it and report it. Below are answers to some of the frequent questions about benefits fraud. If you have more questions, reach out to Equitable Life’s Special Investigations Unit.
Who commits health and dental benefits fraud?
Benefits fraud can be committed by your health care provider, your health care supplier, your dental provider, plan members, plan sponsor, or in instances of collusion, all of the above.
What are the possible consequences of committing benefits fraud?
- Loss of benefits coverage for you and your dependants
- Reduction of benefits
- Loss of employment
- A criminal record
- Financial restitution and/or fines
How can you protect yourself from the consequences associated with benefits fraud?
- Recognize benefits fraud
- Refuse to participate
- Report suspicious or concerning activity to your employer or insurance provider immediately
What are some reasons individuals commit benefits fraud?
People engage in benefits fraudulent activity for a number of reasons including:
- Financial need;
- Pressure from others who are already committing benefits fraud;
- Lack of knowledge – a provider suggests it and the individual trusts the provider and is unaware that what they are suggesting is wrong;
- Entitlement – these are my benefits and I am entitled to the money;
- They don’t believe there is any harm – the money would have been spent anyway; and
- They are unaware of, or do not think about the consequences.
Could you receive a criminal record for committing benefits fraud?
Yes. Fraud can be a serious crime with serious consequences. If charged by the police and convicted of benefits fraud you will have a criminal record.
Could you lose your job?
Benefits fraud is a serious matter that an employer could take into consideration when determining if an employee is responsible and can be trusted.
How do I report benefit fraud?
Benefits fraud affects everyone, and it’s our shared responsibility to report it when we see it. If you suspect that a co-worker or health or dental service provider is committing benefits fraud, you can report it to Equitable Life’s Special Investigations Unit by email at: firstname.lastname@example.org or through our tip line at: 1.800.265.8899. You can also report it anonymously to the larger insurance industry via this link: https://www.clhia.ca/web/CLHIA_LP4W_LND_Webstation.nsf/page/0584182ACA6A87FA85257F1400706E6B!OpenDocument
How do people get caught committing benefits fraud?
Insurance companies have elaborate systems and technology that allows them to detect and review suspicious claims activity. Most insurance companies also conduct random audits and have investigative teams designed for the purpose of reviewing red flags and suspicious claims activity. Investigative tips come from many sources, and there are many ways in which red flags and concerns can be presented, identified and reviewed.
Can health or dental providers commit benefits fraud?
Yes. In addition to plan members and their families, health providers can commit claims fraud.
Group benefits fraud affects everyone, and it’s our shared responsibility to report it when we see it. If you suspect that a co-worker or health or dental service provider is committing benefits fraud, you can report it to Equitable Life’s Special Investigations Unit by email at: email@example.com or through our tip line at: 1.800.265.8899. You can also report it anonymously to the larger insurance industry via this link: https://www.clhia.ca/web/CLHIA_LP4W_LND_Webstation.nsf/page/0584182ACA6A87FA85257F1400706E6B!OpenDocument