By providing group health benefits coverage, your employer is investing in the health of you and your family. As a plan member, you share in the responsibility of protecting your health benefits plan from abuse.
Health benefits abuse directly impacts you, the plan member. It can increase the cost of providing a benefits plan, potentially resulting in increased premiums or in some cases, reduced or lost coverage.
What does health benefits abuse look like?
Health benefits abuse can be carried out in a number of ways:
- A healthcare provider overbills for a service, charges for a treatment or service they didn’t provide or performs unnecessary medical services.
- A plan member submits a claim for a service they didn’t receive or claims more for the service than they were billed.
- A plan member and their healthcare provider work together to submit claims for products or services that would not be covered under the health benefits plan or that the plan member did not receive.
For example:
- Billing a spa treatment as a therapeutic massage, or teeth whitening as regular dental care.
- Purchasing regular retail footwear or sport shoes and submitting the claim for reimbursed for orthopaedic shoes.
How you can protect against health benefits abuse:
Keep your health benefit information confidential, particularly your plan member personal identification number and password. While some healthcare providers such as dentists may require your plan or policy number, prior to providing this information and other personal information, it is important to confirm that the healthcare provider is a licensed professional and/or a member of an accredited association.
Keep coverage details and benefit maximums private. Your treatment should be based on medical needs, not your coverage.
Validate the credentials of a healthcare provider before seeking treatment, service or a product.
Check your receipts from your healthcare provider. Ensure they accurately reflect the treatment, service or product you received.
Don’t leave signed blank claim forms with a healthcare provider or their receptionist. Only sign the claim form once you have confirmed that it is accurate and complete.
Report suspicious activity anonymously to Equitable’s Investigative Claims Unit at 1.800.265.8899 or email investigations@equitable.ca.
What we’re doing to protect your health benefits plan from abuse:
Equitable is responding to health benefits fraud and abuse and protecting both you and your plan members through detection, investigation and action.
We have an Investigative Claims Unit team made up of skilled consultants who specialize in risk management.
The team is responsible for:
- Implementing preventative strategies;
- Investigating suspicious billing patterns or claims activity; and
- Conducting frequent claims audits. The Unit takes action against abusive activity of healthcare providers through a delisting of these providers and recovering money improperly obtained.
The team also takes action against abusive activity of plan members, including terminating benefits coverage and recovering money improperly obtained. In many cases, the employer would be notified of a plan member investigation.
Benefits fraud is a crime.
The Fraud = Fraud program was created to educate Canadians about health and dental benefits fraud and its real consequences. It is sponsored by the Canadian Life and Health Insurance Association with the support of its member companies. Learn more.
Click on the image below to watch CLHIA's fraud awareness video.
