Coupled in crime
2 members—a couple—enrolled in group benefit plans with their employers and submitted fraudulent claims over a period of time for services not received.
The members were identified by our analytics team and their ability to submit online claims was suspended. We contacted the providers who confirmed that they did not provide services to the members. Finally, we contacted the members for an explanation, and for some claims they provided falsified receipts to support the claims.
The case was reported to the 2 plan sponsors. The members’ access to the online portal was terminated. We contacted the members requesting repayment, and the full amount overpaid was recovered from the members. The groups terminated both members.
Identified by analytics team
Full funds recovered
Investigation with law enforcement avoided
This case is an example of the consequences to members who knowingly submit false claims and documentation. These consequences are less severe if members cooperate with Alberta Blue Cross®, and the issue may be resolved without having to resort to law enforcement or legal proceedings.
The information on this page is based on data provided by our private book of business.