Benefits fraud can happen when an offer seems just too good to be true.
When you think of benefits fraud, you may think of a ringleader recruiting teams of people, colluding with a crooked provider to bilk the insurance company out of thousands of dollars’ worth of false claims.
However, benefits fraud could be happening all around you, every day. When a local optical store offers to put a pair of designer sunglasses through a vision care plan, a salon issues a massage receipt for a facial, a dental office bills for a few extra units of scaling, or an employee inflates the total when submitting through an online claims tool, it impacts the bottom line of a benefits plan.
Employees may believe they had not done anything wrong. When the professional in the white coat says it’s OK, the natural reaction is not to ask questions. Those who are aware that they are doing something wrong may see this as a victimless crime, or feel that they are entitled to compensation through the benefits package.
The consequences to the employee can be severe, and can range from discipline at work, loss of benefits coverage, loss of employment, and even criminal charges. Benefits fraud and abuse hurts the sustainability of the plan as a whole. In the long term, this may result in increased premiums, more employee cost-sharing, or a reduction in benefits.
March is Fraud Prevention Month in Canada, and all stakeholders should take the time to review what they can do to prevent benefits fraud.
Insurance carriers should continue to enhance their data-mining capabilities to identify and investigate unusual claiming patterns, and delist providers who display unethical behaviour.
Plan sponsors need to educate employees about their plans, and about benefits fraud and abuse. Employers can set up a tip-line, and thoroughly investigate any reported incidents.
Employees should become familiar with their benefits package, review claims that are being submitted on their behalf, and be on the lookout for deals that seem just too good to be true.
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