Welcome to Fraud Prevention Month!
Fraud Prevention Month is an annual public awareness campaign that helps Canadians recognize fraud attempts.
Benefits fraud costs billions of dollars each year in Canada.
When fraud occurs, plan costs increase, which puts your coverage at risk. It isn’t the insurer who is defrauded of money – it’s the Trust, it’s your CUPE EWBT plan. That means everyone pays.
It’s your CUPE EWBT benefits plan that is affected by fraud – and that includes all the other members who participate in the plan, too. Fraudulent claims have a ripple effect on your benefits plan. When false claims are submitted, the entire plan suffers the consequences, as the pool of funds meant for legitimate claim reimbursements and opportunities to improve coverage is directly impacted.
In the end, it’s our coworkers and friends who suffer, as money that could be used to pay for benefits is diverted to cover fraudulent claims instead. The best way to prevent this from happening and protect your group benefits plan from fraud is to remain vigilant and keep an eye out for questionable behaviour.
What is Benefits Fraud?
Fraud is not always easy to detect, and in some cases, you may not even recognize it. Learning how to recognize benefits fraud is the first step towards preventing it.
It’s also important to note that there is a difference between Benefits fraud, the abuse of Benefits, and waste of Benefits. Fraud is a crime, while abuse and waste are not.
| Fraud Intentional deception when submitting claims resulting in personal gain | Abuse Excessive, improper, or unnecessary use of benefits | Waste Unintentional errors resulting in improper benefit payment |
Common Examples of Fraud
- Using benefits for one person eligible under a benefit plan to pay for a service that someone else received;
- Service providers falsifying medical conditions to provide products that are unneeded; or
- Submitting a claim to an insurance company for services that were not actually received.
Imagine this – you got a new pair of glasses last year, which cost $350, but are now hoping to get a pair of prescription sunglasses for your upcoming vacation. With your CUPE EWBT benefits plan, you have a maximum of $450 covered in a rolling 24-month period. You explain the situation to your provider, and they suggest that you split the fee for your prescription sunglasses between your coverage and your dependent’s coverage, to cover the full cost.
This may not seem like a big deal, but it does happen and is an example of health benefits fraud.
Transferring unused benefits to others results in false claims, fully affecting the Trust’s ability to continue to provide effective and affordable benefits to all members.
Signs of Fraud
There are many different reasons benefits fraud is committed, including financial need or wanting to “cheat the system”.
No matter the reason, the result is the same: an increase in plan costs that leads to increased premium costs for all members.
Sometimes, providers depend on a lack of knowledge from their customers and submit fake or inflated claims. This is why it’s important to educate yourself about the warning signs of fraud.
Potential Signs of Fraud
- Someone asking for your ID and password on the My Canada Life at Work website;
- Your receipt from a provider does not accurately show the service you received;
- Being asked questions about how much your plan covers before the bill is wrung through;
- Providers or retailers encouraging you to purchase additional services or products that you don’t need.
For example, if you go to buy compression stockings, your provider may ask how much your organization’s benefit plan would cover for the purchase. With your CUPE EWBT benefits plan, you are covered for two pairs every 12 rolling months. Once the provider hears this, they may suggest that you pay for two pairs (but receive only one), submit the receipt, and be reimbursed in full by your plan.
Check your service receipts from your provider at the point of sale, just like any other transaction. We must stay vigilant about fraud to ensure the CUPE EWBT can continue to provide meaningful, affordable benefits for all.
For your CUPE EWBT plan, fraud results in increased plan costs, and that leads to higher premiums which means less affordable coverage for everyone. Let’s work together to protect the integrity of your CUPE EWBT plan and ensure it continues to benefit us all for years to come.