Our team of highly skilled auditors are trained to detect fraud and abuse, and to lessen the risk to the company’s benefit programs for its plan sponsors and plan members. This team is supported by a network of query analysts, medical and dental consultants, and legal advisors.
In addition to our auditors, we provide regular fraud awareness training to claim analysts and inquiry resources.
Our Process for Investigating Fraud
Our auditors investigating tips, coordinate mail audits and conduct onsite audits. In some cases, the auditor may also recommend:
- To escalate the matter to law enforcement agencies when the evidence supports the potential for a successful prosecution, or;
- Lodge a formal complaint with the provider’s regulatory body / association when the evidence supports the likelihood of disciplinary action
What you can do as a provider:
Protect your unique, registered Provider ID number. Consider it as confidential and valuable as your bank account information.
If you change business locations, consider changing your Provider ID number and monitor staff utilization to ensure proper claim submission. Misuse of this number can result in suspension of access to the eClaim service, termination of approved provider status or recoveries of money paid to the provider for claims submitted.
Fraud and Ethics Reporting Service
Medavie Blue Cross has introduced an anonymous tool to help address and prevent health care fraud and abuse and ensure ethical behaviour in all our dealings – the Medavie Blue Cross Fraud and Ethics Reporting Service.
The Fraud and Ethics Reporting Service empowers our employees, plan members, providers, and the general public to take an active role in preventing or addressing fraudulent or unethical behaviour. Confidentially voice your concerns with our professionally-trained agents 24 hours a day.
Some of the potentially fraudulent or questionable behaviours you might want to report include:
- suspected fraud of health benefits
- substance abuse
- workplace violence
Here’s how the confidential Fraud and Ethics Reporting Service works:
- You can call toll free 1-800-661-9675 to reach the service or click on ‘Submit a report’ to send in an electronic report
- You will be issued a User ID and password to access your file, update information and see any response to your report
After you file your report:
- Once all identifying information has been removed, the agent will forward the report to Medavie Blue Cross to determine if follow up is necessary.
- To access your file, update information or see any responses to your report, you can click the Fraud and Ethics Reporting Service link or call toll free 1-800-661-9675. You will need your User ID and password to access your file.
Other Fraud Prevention Contacts
Fraud or unethical behaviour can also be reported anonymously by contacting any of the departments listed below:
Group and Individual Business Customers:
Toll Free: 1-800-661-9675
Government Programs Customers:
For Veterans Affairs Canada, Canadian Forces and Royal Canadian Mounted Police
Toll Free: 1-866-485-5500
Immigration, Refugees, and Citizenship Canada
Toll Free: 1-877-497-3914
The Canadian Health Care Anti-Fraud Association (CHCAA)
The CHCAA w founded in 2000 to give a voice to the p ublic and private sector health care organizations interested in preventing fraud in the Canadian health care environment.
Website: Canadian Health Care Anti-fraud Association (CHCAA)