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Benefits fraud

3 minute read

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.

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.

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.

Our 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 a criminal complaint and we go through the civil courts 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.

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.

Got a tip for us? Drop it here.

If you’ve noticed any suspicious or fraudulent activity,

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The information on this page is based on data provided by our private book of business.