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:
Changing behaviour.
Increasing our presence.
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.
Member fraud occurs when the benefit plan member misrepresents the service or product they claimed in any way. On occasion, people may commit fraud unintentionally. However, even unintentional fraud is illegal and may carry serious penalties.
Here are some forms of member fraud to watch out for:
Services not received—submitting for products or services not actually provided.
Substitutions—substituting actual services or products received that are not covered for ones that are. For example, purchasing non-prescription sunglasses and claiming them as prescription.
Identity sharing—sharing your coverage or ID number.
Forgery—creating, forging or altering receipts.
Missed or cancelled—submitting claims for missed or cancelled appointments.
Double doctoring—going from one prescriber to another in order to obtain multiple prescriptions for the same product.
Switching the claimant—claiming under another plan member’s name when you have reached the benefit type maximum. For example, claiming a teeth cleaning under your spouse’s ID number.
Accepting incentives—free gifts (gift cards, cash, material items), when purchasing a product or service, can be used to inflate the price of the product or service.
How can you help prevent member fraud?
Protect your information and ID number.
Never share your policy number or other benefits information, and make sure your health care provider verifies your identity during appointments.
Monitor and submit accurate claims.
Always pay claims in full before submitting, and if your provider submits on your behalf, make sure you receive a statement of what was claimed.
Double check your information.
When entering a claim, make sure all the information you entered is correct before hitting submit. This will help you avoid unintentionally committing benefits fraud.
Keep your receipts.
Make sure all receipts contain the correct name, date and benefit type. Keep receipts for at least one year.
Provider or retailer fraud occurs when a health care service or product provider misrepresents a claim, deceives a customer or deceives a health plan provider in order to receive a greater reimbursement.
Here are some forms of provider fraud to watch out for:
Forgery—creating, forging or altering receipts.
Switching the claimant—claiming under another plan member’s name when the patient has reached their benefit type maximum.
Services not received—submitting a claim for products or services not actually provided.
Claim inflation—claiming for a more expensive service than the service that was actually provided.
Substitutions—substituting actual services or products that are not covered for ones that are.
Unbundling—claiming separately for procedures that are actually part of a single procedure.
Masquerading as health care professionals—delivering health care services without proper credentials.
Providing incentives—providing purchase incentives such as gift cards, cash, material items or a point system.
How can you help prevent provider fraud?
Ensure receipts are accurate.
Make sure all receipts contain the correct name, date, charge and benefit type. Ensure receipts and invoices are not
created for a service or product not yet received,
billed or submitted over multiple days,
submitted for missed or cancelled appointments, or
submitted for substituted products or services.
Maintain documentation.
Keep charts, records and documentation to support claims. Retain claim records for a minimum of two years or as outlined by applicable professional regulations.
Follow reimbursement guidelines.
For plan member reimbursement claims, do not obtain a signed blank claim form, complete a claim form or submit a claim form on behalf of the plan member. If you must submit a claim on a patient’s behalf, verify their identity through a form of photo identification and their Alberta Blue Cross® ID card.
Avoid incentives.
Do not provide a plan member with purchase incentives such as gift cards, cash or material items. This includes providing incentives through a finance company associated with the provider.
Maintain qualifications.
Be qualified and licensed. Operate within the principles of a governing professional college and association as recognized by Alberta Blue Cross® and operate within the laws of the province where the services are delivered.
Collusion occurs when a plan member and health care provider or retailer work together to commit fraud. These crimes are usually committed by members and health care providers from the same community.
Here are some forms of collusion to watch out for:
False submissions—submitting claims for missed or cancelled appointments.
Claim inflation—claiming for a more expensive service than the service that was actually provided.
Misrepresenting services—submitting claims for services or products not offered.
Switching the claimant—claiming under another plan member’s name when another plan member has reached their benefit type maximum.
Incentives—submitting a receipt for products or services not provided while receiving or offering in-store credit for products or services that are not covered by the benefit plan. In some cases, gifts may be provided by inflating the price of the product or service.
How can you help prevent collusion?
Ensure accurate receipts.
Make sure all receipts contain the correct name, date, charge and benefit type. Ensure receipts and invoices are not
created for a service or product not yet received,
billed or submitted over multiple days,
submitted for missed or cancelled appointments, or
submitted for substituted products or services.
Avoid incentives.
Do not provide or accept incentives such as gift cards, cash or material items. This includes providing incentives through a finance company associated with the provider.
Keep documentation.
Keep charts, records and documentation to support claims.
Maintain professionalism.
Operate within the principles of a governing professional college and association as recognized by Alberta Blue Cross® and operate within the laws of the province where the services are delivered.