Fraud within the Benefits industry is a huge expense to the tune of billions of dollars every year! Managers of employee benefits plans are well aware that fraud occurs, and not just from plan members. Service providers, clinics, facilities, plan sponsors and third parties can commit fraud, and each type of fraud requires a different investigative strategy.
A couple of very simple examples of fraud are when plan members submit suspicious paramedical claims OR when service providers can authorize unnecessary treatments or products, or even falsify receipts for services or products which were billed but not provided. These types of fraud require thorough investigation of the receipts.
There are a range of small shops and clinics that might engage in fraud, such as illegal Orthotic shops, medical equipment stores, and massage clinics. Massage parlors should always be verified as they can issue receipts to clients to claim non-therapeutic services as a massage. Some companies are involved in organized crime and human trafficking, and warrant a request for verification of a legitimate business license and research into any complaints. Are the practitioners licensed, certified and/or registered in the province in which they are practicing? Knowing this information is a very important part of ensuring the legitimacy of any claim – all legitimate receipts will include all of the necessary registration information for practitioners.
Plan sponsors might also engage in fraud. For example, they could submit false claims from their own facilities, or add individuals not employed at their workplace to their plan. They can even have fake facilities. It is unfortunate that even sponsors need to be verified and their activities monitored to ensure they are not engaging in fraud.
Employee benefits managers are seeing an increase in fraudulent claims. It is not surprising that during the COVID-19 pandemic, when household incomes may have dropped if one partner lost a job and their benefits, the other partner might engage in fraud to submit their partner’s receipts as their own. When times are tough, people are more tempted to get “creative” with covering their costs and this places an added burden on employee benefits managers to become investigative sleuths.
At Health Risk Services, we take Fraud very seriously, which is why each and every claim is adjudicated prior to being paid! There is no automatic approval here – we are the guardians of the employer vault! We know how to recognize and pursue a wide variety of fraudulent activities.
We would like you to know more about how Health Risk Services can assist you with a 2021 plan to identify and address fraudulent benefits claims, so please schedule a Complimentary Consultation with us.
At Health Risk Services we will Empathize, Educate, and Empower you and your team in 2021!
To schedule your Complimentary Consultation with Health Risk Services
Please Call 403-236-9430 OR email: [email protected]