Collusion—committed by a plan member and provider working together.
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 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.
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 charts, records and documentation to support claims.
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.
Report suspicious activity.
If you suspect benefits fraud from a plan member or health care provider, report it to Alberta Blue Cross®.
Types of fraud.
Benefits fraud can come in many different forms. Health care providers or plan members might submit claims for products and services that weren’t actually provided. In some cases, plan members might receive a service or product not covered by a benefit plan, then submit a claim for something that is.
Member fraud—committed by a plan member.
Examples include forging receipts, submitting a claim for services not received, sharing benefits with others, misrepresenting services and identity theft.
Provider fraud—committed by a health care provider.
Examples include submitting false claims, claiming for services more expensive than what was provided, providing incentives to plan members, misrepresenting services and submitting claims under another person’s name.