Health insurance fraud is the intentional act of submitting false, deceiving or misleading information for the purpose of financial gain. Fraud can lead to significant financial losses to a benefit plan and result in higher premiums and decreased coverage. Medavie Blue Cross is committed to protecting the integrity of our benefit plans for our policyholders and members by monitoring for and resolving any abusive or fraudulent activity.
Both fraud and the abuse of health insurance benefits are serious issues that can greatly impact your benefit plan.
Abuse occurs when a health care provider, a group plan member or an individual policyholder exploits the plan provisions or the health profession guidelines. This includes receiving services that are not part of a therapeutic treatment for illness or injury, or excessive use of benefits.
Fraud is an intentional deceptive act to obtain a financial gain. Examples of health insurance fraud include double billing, or charging more than once for the same service, and using the coverage of a dependent for a service that you are receiving.
As a group plan member, plan sponsor or individual health policyholder, you can help us prevent fraud. Ask yourself:
Do I know a health care provider who:
- Submits claims on my behalf for services or supplies I did not ask for, or did not receive?
- Misrepresents non-covered services as covered in order to bill for non-eligible benefits?
- Sells supplies or performs treatments that are not medically necessary and misrepresents information on the invoice in order to bill for them?
Do I know an individual who:
- Has no known medical condition but obtains services or treatments that are not medically necessary and claims the service through their health insurance?
- Gets workers’ compensation benefits or other disability insurance benefits but isn't disabled?
- Has submitted a falsified or forged health-related claim to an insurance company?
- Has returned a product for a refund after receiving payment from the insurance company (medical equipment, orthopedic supplies, etc.)?
Fraud Prevention Tips
Here are a few things you can do to help protect yourself and others from becoming a victim of fraud:
We perform regular claim reviews to protect our plan sponsors, service providers and benefit programs. The audit ensures we have proof of the services that have been rendered, detects claim irregularities, finds infractions and increases awareness of insurance fraud and abuse.
Our auditors investigate tips, coordinate mail audits and conduct onsite audits. In some cases, the auditor may also recommend:
- Escalating the matter to law enforcement agencies when the evidence supports the potential for a successful prosecution, or;
- Lodging a formal complaint with the provider’s regulatory body or association when the evidence supports the likelihood of disciplinary action
What you can do as a plan member
Know your audit rights and the conditions of using Medavie Blue Cross benefits by reading the benefits booklet you received when you became a member. Have conversations with your health providers to ensure they maintain accurate records to support any claims you may be required to submit.
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.
Medavie Blue Cross has introduced a 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 Medavie Blue Cross employees, plan members, providers, and the general public to take an active role in preventing or addressing fraudulent or unethical behaviour. The service, administered by an external company, is a safe place to confidentially voice your concerns. It is quick, easy and its professionally-trained agents are available 24 hours a day.
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.
Fraud or unethical behaviour can also be reported anonymously by contacting any of the departments or external partners listed below:
The Canadian Life and Health Insurance Association