What is Benefit Fraud and Abuse?

fraud and abuse group benefits plan

Group Benefits Plans, Abuse and Fraud

​​Group benefits are an essential aspect of employee compensation in Canada. These benefits are designed to provide employees with access to necessary medical and dental care and protect their financial well-being. Unfortunately, some individuals and organizations exploit these benefits through fraudulent and abusive practices. Benefits fraud and abuse is a severe issue that has amounted to more than a $100 million loss for insurers in Canada. These schemes may not be well-known to the Canadian public. Still, this type of fraud has resulted in serious consequences that can include increased premiums, an inability to obtain benefits through a provider, and a reduction of a group benefit plan for both employers and employees. More so, these crimes can culminate in a much starker result for those committing them that is more than just reimbursing what was stolen, as significant fines, job loss, and jail time are potential punishments that will be imposed. All of this may beg the question of what benefits fraud and abuse are and what can be done to prevent it from happening. 

Discover what benefits fraud and abuse is and the varied ways employers and insurers can mitigate the risks of this type of fraud.

What is Benefit Fraud and Abuse?

Group benefit fraud and abuse occur when you give false information and claim expenses under your employer benefits plan for reasons of financial gain. The abuse element of this criminal offence emerges when you obtain a substantial amount of treatments and products than what is deemed reasonable or acceptable, such as taking inappropriate incentives of any kind. Other examples of benefit fraud and abuse can include forging documents by manually editing receipts, submitting an expense that is ineligible under the group benefit plan, or submitting a claim for a treatment that you, or your dependent, did not acquire. As aforementioned, these types of fraud will result in reduced coverage, completely eliminated coverage, total repayment of what was stolen, job loss and having to answer to law enforcement. 

Who Commits Fraud and Different Types

Benefits fraud and abuse can be committed by individual members of a benefit plan, health and dental providers, or both. There are many forms of benefit fraud committed by individuals and organizations, but one form is healthcare provider fraud, where providers bill for services that were not performed or charge excessive fees for services rendered. Additionally, some employees may abuse their benefits by claiming excessive amounts for treatments they did not receive, and some employers may reduce the coverage provided to employees without their knowledge.

Measures Being Taken to Address the Problem

Several measures have been taken to address the problem of group benefits fraud and abuse in Canada. One such measure is the creation of the Canadian Health Care Anti-Fraud Association (CHCAA), which works to identify and combat fraud and abuse in the healthcare system. The CHCAA uses a variety of tools, including data analytics, to identify patterns of fraud and abuse and take action to prevent it.

Another proactive measure being taken is the increased use of technology to monitor and detect fraudulent activity. Many healthcare providers are now using sophisticated software to identify unusual patterns in billing, such as billing for services that were not performed or billing for services that are not covered by the benefits plan. In addition to these measures, the Canadian government is taking steps to educate the public about the issue of group benefits fraud and abuse, which includes providing information on how to identify and report fraudulent activity and creating programs to help individuals and organizations prevent fraud and abuse.

Individual Action

Employers and employees should all undertake proactive measures to protect themselves from falling victim to benefit fraud and abuse. Such actions can include ensuring that your passwords are strictly confidential, utilizing multi-factor authentication on personal accounts, verifying your claims submission to clarify that everything is accurate, checking all of your claims receipts, and reporting fraud and abuses when you notice any suspicious and nefarious activity. When employees and employers add another layer of security to protect themselves from this criminal activity by taking these extra steps, benefit fraud and abuse will become a mitigated risk. 

At Health Risk Services, we help managers of benefits plans make strategic decisions to craft cost-effective personalized plans that can assist you and your organization to address benefit fraud and abuse. Whether the solution of preference for your company is adding additional support programs, renovating your existing coverage, or crafting intentional messaging, Health Risk is here to help!

To schedule your Complimentary Consultation with Health Risk Services, please call 403-236-9430 OR email: [email protected]