Benefits fraud occurs when an individual intentionally submits false or misleading information about the health or dental benefits they received under their employer's benefit plan.
The most common types of fraud committed by service providers and benefit plan members include:
- Billing for services not rendered
- Up-coding of services
- Up-coding of items
- Duplicate claims
- Excessive services
- Unnecessary services
- Falsifying Patient Records
- Co-Pay Activities
Three factors which can cause providers and plan members to commit fraud are entitlement, opportunity and rationalization. Together, these three factors make up the commonly recognized fraud triangle that can contribute to the desire to commit fraud.
This is what motivates the crime in the first place. The individual has a financial problem that they are unable to solve through legitimate means, so they consider committing an illegal act to solve their problem.
Examples of pressures that lead to fraud include:
- Inability to pay one’s bills;
- Drug or gambling addictions;
- Need to meet productivity targets; and
- Desire for status symbols such as a bigger house, nicer car etc.
Opportunity is the method by which the fraud can be committed. The person must see some way that they can solve their financial problem with a low perceived risk of being caught.
It is critical that the perpetrator be able to solve their problem in relative secrecy, as many people will commit white-collar crimes to maintain their social status. For instance, they might steal to conceal a drug problem. If the perpetrator is caught this may hurt their social status as much as the underlying problem they were trying to conceal.
Most fraudsters are first time offenders with no criminal past. They do not view themselves as criminals. They see themselves as ordinary, honest people who are caught in a bad situation. As a result, the fraudster must justify the crime to themselves.
Common rationalizations include:
- “I was only borrowing the money”
- “I was entitled to the money as part of my benefit plan”
- “I am underpaid by my employer”
- “My employer is dishonest and deserves to be fleeced”
Is it worth it?
Research shows that 75% of insured Canadians surveyed think that the only consequence of benefits fraud is that their premiums will go up. Only 25% believe they could lose their job. The truth is, committing and contributing to benefits fraud is not only harmful to you, but can permanently impact and affect your spouse, children and family as well. Insurers often terminate the benefits of employees found committing fraud and recover the money improperly obtained. They will also notify employers of the crime, which may put the employee’s job at risk.
Find out for yourself – is it worth it?
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 Fraud Investigations and Risk Management team by email at: email@example.com or through our tip line at: 1.800.265.8899. You can also report it anonymously to the broader insurance industry.