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Benefits fraud

What happened in 2020

3 minute read

Fraud is always evolving—and we evolve right alongside it. This ensures that not only are we up to date on the latest fraud cases and trends, but that we incorporate a range of lessons learned to make our fraud strategy stronger.

Our fraud strategy focuses on four key areas:

Education

Detection

Investigation

Resolution

Each year, we look back at our work to see the achievements we made and milestones we hit in benefits fraud. And each year, the numbers show us that we’re having a meaningful and significant impact on fraud.

Here’s a look at our 2020 milestones

14%

14 per cent decrease in claim amounts paid following our audits.

$4M

$4 million in identified funds for recovery.

69%

69 per cent of our provider fraud cases were identified through analytics.

We were able to achieve these milestones thanks to the analytics, audits and zero-tolerance policy we employ.

Analytics

Our first line of defense against benefits fraud is analytics—studying the data. We have a dedicated team of data scientists and data analysts who look for any sign of abnormal behaviour, such as

  • abnormally high dollar amounts claimed,
  • family members maxing out their benefit plan in a short time frame,
  • unusual claiming trends and behaviour for providers or members,
  • multiple members from the same group plan using the same health care provider,
  • an individual plan member frequently changing their banking information, or
  • two or more unrelated plan members using the same bank account.

In 2020, our advanced analytics achieved the following:

69%

69 per cent of health care providers identified for audit through analytics resulted in fund recovery or other remedies.

24%

24 per cent of plan members identified for audit through analytics resulted in fund recovery or other remedies.

Audits and investigations

After a suspicious member or provider has been flagged by our analytics team, we escalate and conduct an audit or investigation. We deploy multiple layers of protection that include

  • reviewing and verifying a claim prior to payment,
  • auditing a plan member or health care provider after a payment has been made, and
  • investigating the claims history of a plan member or health care provider.

In 2020, our dedicated team of analysts and investigators achieved the following:

515

Audited 515 health care providers.

18K

Audited 18,000 plan members.

13

Uncovered 13 cases of deliberate deception.

$4M

Identified over $4 million in funds for recovery.

Zero-tolerance policy

Our success is dependent on the partnerships we’ve built with our external partners. After a case of benefits fraud is confirmed, we work with law enforcement agencies to file criminal complaints against the perpetrators, and we go through the civil court system to recover any funds we paid. We may also take additional steps, such as

  • reporting a health care provider to their association or college,
  • terminating agreements with a health care provider,
  • removing a health care provider from our list of eligible providers, and
  • suspending a plan member’s ability to submit claims online.

In 2020

314

314 health care providers were identified for fund recovery, terminated agreements, professional reprimand or removal from our list of eligible providers.

38

38 health care providers were removed from our list of eligible providers.

306

306 tips were investigated.

Our success factors

While we aim for specific metrics and targets every year, our fraud strategy is driven by three main goals:

  1. Changing behaviour.
  2. Increasing our presence.
  3. Driving recovery of funds.

Changing behaviour

Our ultimate goal is to not just catch instances of benefits fraud, but to prevent it entirely. By monitoring the claiming patterns of the health care providers we’ve already audited, we can get a measure of how we’re accomplishing that goal. Following an audit, we typically see a 14 per cent decrease in claims paid to health care providers. These numbers suggest that our work is both effective and impactful.

Increasing our presence

One of our greatest assets is the relationships we’ve built and maintained. We measure the total number of interactions we have with health care providers and plan members, and we believe that increasing our presence within that community through education and collaboration will act as a strong deterrent to benefits fraud and abuse.

Driving recovery of funds

Benefits fraud and abuse is not a victimless crime: those costs are passed on to our plan members as higher premiums. To keep our plans sustainable, our most common response to benefits fraud and abuse is recovering the amount we paid in claims.

We take a zero-tolerance approach to fraud. If you’re caught committing benefits fraud, you could be on the hook for any funds that need to be paid back. Not only that, you could face consequences like losing your benefits plan, losing your employment, incurring criminal charges or even facing jail time.

Help us stop fraud

We use several tools internally to catch benefits fraud and recover funds, but we also rely on our community to report it. We receive tips internally from various departments and externally through our fraud hotline and fraud email address.

Got a tip for us? Drop it here.

If you’ve noticed any suspicious or fraudulent activity,

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The information on this page is based on data provided by our private book of business.