How we manage fraud
We take benefits fraud and abuse very seriously. In order to protect your plan, your information and our reputation to the best of our ability, we follow a five-step process to manage fraud.
Some of our fraud management practices include
- monitoring claim patterns,
- running robust analytics processes to identify irregularities so we can focus on areas of greater risk,
- conducting regular audits to ensure compliance with plan contracts and agreements,
- terminating agreements and delisting providers,
- filing official complaints with professional colleges and associations,
- pursuing civil litigation and criminal prosecution where evidence indicates fraudulent activity has occurred, and
- calling for restitution where warranted.
1
Prevent
- Educating health care providers, plan members and plan sponsors on fraud.
- Participating in industry and stakeholder engagement to share insights and collaborate on combating benefits fraud.
- Providing plan design and management expertise, including fraud mitigation.
- Managing a proprietary, real-time claims systems that incorporates hundreds of systems edits.
2
Detect
- Continuous monitoring of claims behaviours for members, health care providers and groups.
- Leveraging machine learning and advanced analytics to identify high-risk claiming behaviour.
- Managing and responding to the fraud tip reporting hotline.
3
Investigate
- Conducting risk-based pre-payment claims verification.
- Conducting member and provider audits.
- Escalating incidents to a dedicated investigation team.
4
Act
- Terminate a plan member’s coverage.
- Terminate agreements.
- Delist health care providers.
- File complaints to professional associations or colleges.
- Pursue civil litigation and referrals to law enforcement.
5
Learn
- Implement any lessons learned.
- Improve internal fraud management practices.