Gary Sawatzky | Chief Operating Officer, ARTA
Group benefits fraud has proven to be a very lucrative way for certain unscrupulous individuals to take advantage of people and group benefit plans in Canada. This form of fraud affects insurers and plan sponsors alike, driving up costs and threatening the sustainability of benefit programs like ARTA’s. It’s especially important to ensure fraudulent actions are detected and abolished given that ARTA’s members pay 100% of the plan premiums, which are directly affected by claims paid by the plan.
Group benefits fraud occurs when covered members or service providers intentionally submit false, exaggerated, or misleading claims to a group benefits plan for financial gain.
Members commit fraud by
- submitting claims for services never rendered.
- altering receipts to increase the submitted claim amount.
- benefit card swapping or using someone else’s coverage.
- falsifying eligibility to get coverage under a plan.
- forging or stealing prescriptions.
- submitting a full claim for the same service to multiple providers.
- abusing narcotics by receiving prescriptions for the same medication from multiple doctors or pharmacies.
- returning items after being reimbursed.
Service providers commit fraud by
- billing for treatments, products, or services that were never provided.
- providing medically unnecessary treatments, products, or services.
- providing false or altered invoices.
- falsifying procedures performed or goods provided to receive payment for non-eligible expenses.
- misrepresenting themselves as licensed practitioners.
- billing for higher-priced services or excessive use of time.
The industry has taken it upon itself to try to reduce the amount of fraud in the system. In 2022 the Canadian Life and Health Insurance Association (CLHIA) launched an initiative through which CLHIA members (insurance providers) share aggregate anonymized claims data for review using artificial intelligence to help determine if claims are fraudulent. For example, their system can determine if a particular provider had an “impossible day” where they claimed three hours of services to ten different providers. Before artificial intelligence, it was not possible to find these types of fraudulent claims simply because of the vast amount of data. However, working with covered members is still the best way to determine if a provider is acting fraudulently.
To ensure you haven’t been the victim of benefits fraud, there are things you can do:
- Keep your benefits ID cards and plan member website login information in a safe place.
- Use the ARTA Benefit Plans for their intended purpose: coverage for eligible expenses incurred for the medically necessary treatment of illness or injury.
- Do not sign blank claims forms.
- Report providers who ask you to pre-sign claim forms to ARTA.
- Make sure your provider or practitioner is licensed with their appropriate regulatory board.
- Do not be enticed by cash rebates or free products.
- Question and stay informed about treatments, products, or services being provided to you.
- Never submit a claim prior to receiving the medical treatment, product, or service.
- Notify and reimburse the plan if you return previously claimed items for a refund.
- Review the Explanation of Benefits form that accompanies your claims summary and report any concerns or billing discrepancies to ARTA.
If you suspect a service provider is acting fraudulently, submit a tip to [email protected] or 1.800.265.5615 ext. 6921. More information about benefits fraud can also be found online at fraudisfraud.ca.
After working in group benefits consulting for twenty years, Gary joined ARTA to serve as Chief Operating Officer in November 2017. Gary has his Certified Employee Benefits Specialist designation.