From backdating a disability claim to submitting a fictitious medical claim to inflating a dental claim, benefits fraud can take many forms. All forms of health and dental claim fraud can increase your employer’s costs for providing benefits and put your coverage at risk.
Anyone who has access to your benefits information can submit fraudulent claims. It could be you or your family members, doctors, dentists or other service providers. Knowing the signs of a potential scam can help you act quickly and confidently when you encounter something questionable.
Red flags to watch for
Here are some proactive steps you can take to protect yourself.
- Avoid doing business with anyone who asks for your passwords, not just for your benefits but for any reason. Sharing your login information for your benefits carrier could put you at risk. Never share your passwords with anyone.
- Be wary of retailers or service providers who ask questions like “What else does your plan cover?” Scammers are especially interested in targeting consumers who have substantial benefits plans.
- Be cautious when retailers try to entice you with incentives to buy more than what you came for. Keep special watch for promotions that are way beyond the norm, such as a free pair of shoes when you purchase orthotics.
- Avoid stores that have more non-medical items than medical items on display. A safer bet is to buy medical items from experts who work in that field: purchase eyewear from your optometrist and orthotics from your foot doctor.
- Stay away from service providers who offer to substitute supplies or services. If they suggest substituting a covered supply or service for something that isn’t covered, decline the offer. Common fraudulent substitutions include:
- A facial or other spa service instead of a therapeutic massage
- Running shoes instead of orthotics
- Designer non-prescription sunglasses instead of prescription eyewear
- Teeth whitening instead of regular dental care
How to recognize health and dental benefits fraud
Learning how to recognize benefits fraud is the first step towards helping prevent it. Common fraudulent activities include:
- Billing for services that never occurred
- Health or dental service providers falsifying medical conditions to provide unnecessary treatments or services
- Health or dental service providers and plan members conspiring to inflate the amount of a claim to ensure full coverage, so the plan member doesn’t have to pay the deductible
- Claiming different services or supplies than those provided
- Transferring unused benefits to others, such as using a dependant’s unused coverage to pay for another plan member’s health or dental expense
If you suspect your health or dental service provider or co-workers are encouraging you to submit a fraudulent claim, or something just doesn’t feel right, report it to your employer or alert Canada Life immediately.
Reporting fraud
Often people will ignore fraud because they don’t want to be labelled a whistleblower or tell on their co-workers – but speaking up could protect your healthcare coverage. If fraud is happening within your group plan, then the plan may get too expensive for your employer, and they may have to cut back on benefits.
Consequences of benefits fraud
If you’re caught committing benefits fraud, you just have to pay the money back, right? That’s what some people think – in reality, the consequences could be far more serious.
- You could lose your benefits: As noted, when plan members commit benefits fraud, premiums may increase for all plan members or your employer may opt to reduce coverage to be able to afford to continue providing benefits. Along with having to pay the money back, you and your co-workers could lose your benefits completely.
- You could lose your job: Benefits fraud could cost you your job. After all, stealing from your employer is a serious offence, and many employers have a zero-tolerance policy for benefits fraud. Being fired for benefits fraud could also impact your chances of being employed in the future.
- You could be charged with a crime: Being convicted may leave you with a criminal record, which can make it harder to find work or travel in the future. Legal consequences can also include fines or, in some cases, jail time.
Protecting yourself and your plan
The cost of benefits fraud in Canada is millions of dollars each year.
When fraud occurs, your employer may be required to pay higher premiums to help cover the loss. This can put your coverage levels at risk as your employer looks for ways to manage the increase in costs.
Did you know you can help protect your group benefits plan from fraud? Here’s how.
- Keep your benefits information confidential: Your benefits information is valuable. Keep your benefits card, contact number and plan details confidential and in a secure place.
- Submit claims online whenever possible: Online claim submission and direct deposit is the most secure form of claims processing. Just be sure to keep your access ID and password private.
- Enable multi-factor verification: Set up multi-factor authentication wherever possible.
- Choose reputable providers: Research your providers to confirm their credentials and identity and avoid providers who offer to misrepresent your claims or recommend treatment or supplies that aren’t medically necessary.
- Check your receipts: Ensure your receipts are correct and accurately reflect the service or supply you received. If your provider submits claims electronically for you, cross-check your copy of this information with the claim statement you get from Canada Life. They should both match up with what you actually received.
- Don’t sign claim forms in advance: Sign one completed claim form at a time, never pre-sign forms.
- Check your claims history: Sign in to your My Canada Life at Work™ account to make sure you’re aware of all your submitted claims.
- Report suspicious activity: If you’re suspicious of any activity or request from a service or medical equipment supplier, report it to us.