Provider or retailer fraud—committed by a health care provider.
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 member 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.
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.
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.
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.
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.
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.