Advances in Fraud Investigations – It’s not you, it’s them!

By March 17, 2023 No Comments
Press Release – March 15, 2023

Group Benefit Insurers have been addressing the submission of fraudulent claims since the inception of group benefits programs. Back in the day, paper claims were reviewed, and fraud was identified with rudimentary manual methods – a date was obviously changed, handwritten receipts etc. As the sources of fraud and the methods evolved, insurers have continued to develop methods to counter this costly practice, approximately 1 billion annually. In recent years with the advent of the electronic submission of claims, artificial intelligence-based algorithms have been developed to scan large amounts of claims data to identify anomalies and trigger investigations.

What is the Source of the Majority of Fraud?

Though an individual committing benefit claim fraud (ex. submitting a claim twice) does account for a significant amount of fraud claims, there are enough deterrents in place to keep most of us honest – random receipt requests, daily claim submission limits etc. The bigger problem resides with shady providers and organized crime syndicates. In recent years, several sophisticated crime schemes have been identified and stopped. A high-profile example was the TTC orthotics ring – here’s a link if you’d like to read the details.

What Are Insurers Doing to Stop It?

In collaboration with the Canadian Life and Health Insurance Association (CLHIA), insurers are developing an industry strategy to leverage the knowledge and expertise to reduce the time it takes to act on those exploiting health benefit plans. The strategy is to work to conduct joint investigations into service providers suspect of fraudulent claims submissions. If they are defrauding one insurer, they are likely defrauding another. Most insurers now post a list of providers who are not in good standing, and the list is going to get longer.

At MFG we scrutinize your claims reports to identify any anomalies in claims patterns. Though only aggregate data is provided for privacy reasons, patterns still emerge. If a pattern is detected, we prompt the insurer to look deeper into the claims and often a fraud investigation is initiated. In most cases, we find the source of the issue are the providers submission issues.

What Do We Tell Our Employees?

Employers should remind their employees to check with their insurer before receiving services from a new provider. Check the insurer’s member site for a list of approved providers, or alternatively (depending on the insurer) providers who are not in good standing. If you are unsure, ask the provider for a predetermination for the services you are signing up for and send the details to your insurer for confirmation of what will be covered…and share this with employees, it’s their plan too!

If you have any questions or feedback about your provider submission experience, reach out. We are here to help harmonize your Total Rewards Program with your Employee experience.