Protecting your benefit plan
Pacific Blue Cross believes that the vast majority of plan members, health and dental
providers, and groups are honest; however, there are a small percentage of people
who will engage in fraud and abuse.
When fraud or abuse occurs, your benefit plan costs rise, which means higher plan
premiums for consumers—for British Columbians like you. Individual plan members
and group plan sponsors must ultimately pay every dollar of fraud or plan abuse.
We're committed to protecting your benefits from insurance fraud and abuse and as
a plan member you can help by understanding insurance
fraud and abuse and what to do about it.
Understanding insurance fraud and abuse and what to do about it
What is insurance fraud and abuse?
Insurance fraud is the intent to obtain reimbursement for claimable goods or services
that were neither received nor provided. Examples of insurance fraud are:
- Misrepresenting items supplied on receipts
- Member returning items after reimbursement and not refunding PBC
- Submitting claims for services not rendered
- Altering receipts
Insurance abuse is any actions that use the benefit plan in a way that is contrary
to the intended purpose of the benefit, which results in unnecessary cost to the
plan. Examples of insurance abuse are:
- Providing medically unnecessary treatments
- Excessive use of benefits
Who commits insurance fraud?
Anyone that has access to your personal benefit information can commit insurance
fraud or abuse.
How does insurance fraud affect you?
Insurance fraud and abuse may reduce the member's benefits and in some cases, high
fraud risk benefits may be eliminated by the employer/plan sponsor altogether because
of the financial risk.
What can you do to protect yourself from fraud?
Members can protect themselves and others from health insurance fraud and abuse
by taking these steps:
- Keep your PBC ID card and information in a safe place and report lost or stolen
cards to your employer or PBC.
- Monitor your claims submitted by the provider. You can review your claims information
via CARESnet, Pacific Blue Cross' online access to claims and benefit information
for members. (pac.bluecross.ca)
- Never allow anyone else to use your PBC ID card.
- Contact PBC if you suspect that someone is committing a fraud against your plan.
Providers can protect their business, as well as their patients/customers from health
insurance fraud and abuse by taking these steps:
- Verify that the patient you are about to provide services for is an actual PBC member
by requesting picture identification
- Ensure receipts are issued for exactly what was provided.
- Validate patient chart information to remittance statements for accuracy.
- Contact PBC if you feel that someone is falsely using a PBC Health and Dental card
or is abusing the plan.
How do I report suspected fraud or abuse?
To report any fraud or abuse you can contact our confidential Whistleblower Hotline
Phone: 1.800 661-9675.
Hotline is administered by CANPRO HRservice's Confidence Line™, an independent
third party to ensure the strictest confidence and you are not required to provide
your identity should you wish to remain anonymous. You will be issued a unique reference
number, which can be used to provide additional information anonymously. The hotline
is available 24/7.
Alternatively you can contact us by mail:
Pacific Blue Cross
Attn: Audit Services
PO Box 7000
Vancouver, BC V6B 4E1
Pacific Blue Cross' Audit Services will investigate all allegations of fraud and
abuse. The information we receive will be kept confidential to the extent possible.
Are calls to the fraud hotline recorded?
Yes, the calls are recorded. CANPRO HRservice's advises every caller that the call
is recorded for accuracy purposes and is strictly intended for the use of ConfidenceLine
What happens to the person being reported?
If the allegation is substantiated, we will take the appropriate action. This may
include but not limited to recovery of funds, termination from the plan or notifying