Preventing group insurance fraud and abuse

 

Healthcare fraud and abuse can cost you money! They can lead to higher group insurance premiums or a reduction in your coverage. Learn how you can protect your plan.

Fraud or abuse?

Do you know the difference between fraud and abuse? Read on to learn more.

Fraud

Fraud is deliberate deception for financial gain at the expense of the group benefits plan. It is illegal.

Examples of fraud:

  • A plan member submits a fake claim.
  • A healthcare professional lies about the treatment they provided.

Abuse

Abuse is more difficult to identify and often stems from a sense of entitlement rather than criminal intent.

It’s usually not illegal but it’s highly unethical.

Example of abuse:

A plan member submits a claim for 6 pairs of compression stockings each year because their group insurance covers them—not because they really need them.

How to prevent group insurance fraud and abuse

  1. Protect your personal information (e.g., your plan booklet and certificate number).
  2. Never sign a blank form.
  3. Only submit claims after you’ve received and paid for the treatment or product.
  4. Check that all your bills and group insurance statements are accurate. Did you receive the treatment or product? Does the amount match what you paid?
  5. Never agree to substitute products or services (e.g., a provider offers to give you a receipt for physiotherapy instead of for the gym membership you paid for).
  6. Be sure you understand what your group insurance plan covers and what it doesn’t.
  7. Before you try a treatment or product recommended by your healthcare provider, make sure it’s medically necessary. If you’re not sure, get a second opinion.

How to report fraud

If you think someone is abusing your group insurance plan, there are 2 ways to report fraud anonymously.