Have you ever thought:
- Using your group benefits dishonestly for your own advantage is no big deal;
- You pay high premiums for group benefits and you’re entitled to use them so you don’t lose them; or
- You could change the date on your receipt so you can be paid back the full amount of your claim?
Whether it’s falsifying a one-time claim, or a larger ongoing scheme, benefits fraud of any kind is still considered fraud. It’s a real crime with real consequences.
What is group benefits fraud?
Benefits (or health insurance) fraud can occur when a clinic, facility, provider or individual intentionally submits false or misleading information about their treatments or services. The most common types of benefits fraud include:
Billing for services not rendered
Creating false claims using genuine patient information, or padding claims with extra charges for services that never took place.
Up-coding of services or items
Billing for more expensive services or products than what was actually provided. For example, billing for a custom made knee brace with rigid components while only giving the patient a slip-on neoprene sleeve.
Submitting false claims
Altering an existing claim receipt, such as the date or dollar amount, in order to claim twice for the same service.
Submitting separate bills for services that would normally be bundled together. For example, a dentist charging separately for the elevation, incision and drainage that are normally included when charging for a tooth extraction.
Excessive or unnecessary services
Billing for services that were not required. For example, an echo cardiogram billed for a patient with a sprained ankle.
Rewards given to entice clinics, facilities and providers into using specific services or products.
Falsifying patient records
Creating a false diagnosis to justify tests, products or treatments or other procedures that aren’t medically necessary.
Billing more than the co-pay amount when services were paid in full by the benefit plan, or waiving the co-pay and over-billing the insurance carrier.
In many of the above examples, the group benefits plan member becomes a party to the fraud by submitting the claim knowing it is false or having received some financial benefit or incentive from the clinic, facility or provider.
Still not sure what constitutes claims fraud? Take this quiz.
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: 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