Member fraud—committed by a plan member.
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.
Report suspicious activity.
If you suspect benefits fraud from a plan member or health care provider, report it to Alberta Blue Cross®.
Related articles
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.
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.
Collusion—committed by a plan member and provider working together.
Examples include submitting for services or products that are not supplied, claiming for a more expensive service than what was provided and claiming under another plan member’s name.