Preventing fraud

Tuesday, January 13, 2015
3.5   based on 84 votes
Get More from Your Benefits, Lowering your out-of-pocket costs

Health insurance fraud hurts us all

By Suzanne Solven, Executive Director, Audit, Investigations and Quality Assurance at Pacific Blue Cross

The Canadian Life and Health Insurance Association estimates that insurance fraud accounts for between 2 and 10 per cent of health care spending in North America. This means that fraudsters potentially divert millions of scarce healthcare resources annually from our members and plan sponsors to their own pockets. This impacts plan sustainability, pushes up monthly premiums and, more importantly, puts your health and wellbeing at risk.

Pacific Blue Cross is committed to protecting the integrity of benefit coverage and uses a combination of approaches to eliminate fraud. We use sophisticated fraud technology that utilizes data analytics on member and provider online claims to spot billing patterns and irregularities. Agreements with health practitioners allow us to conduct audits if we notice unusual patterns of activity. We randomly audit member online claims and verify receipts to ensure that services or products are received. We also investigate tips sent in to the Pacific Blue Cross Whistleblower Hotline.

Whistleblower Hotline

The Whistleblower Hotline allows members, providers and employees to anonymously report fraud. Pacific Blue Cross investigates all incidents reported to the hotline, which is administered by an independent third party to ensure anonymity.

Based on a tip called into our Whistleblower Hotline, Pacific Blue Cross conducted an undercover investigation on two health care providers and one practitioner, who were selling designer handbags and shoes but were submitting them as medical treatments and eligible healthcare products. Members involved were knowingly signing blank claim forms to be later completed by the providers involved. As a result of our investigation, the regulatory body stepped in and imposed a fine and temporarily suspended the practitioner’s license. In addition, we were also successful in shutting down the practices of both healthcare providers.

What if my practitioner offers to waive my co-payment?

In dentistry and other health practices, co-payment—also called co-insurance—is the portion of the bill that a member is responsible for paying. An 80/20 co-payment is common for basic dental procedures such as x-rays, cleaning, fillings and root canals. This means that the dental plan covers 80% of the published fee.

While saving money on your co-payment may seem like a good deal, it’s a form of insurance fraud. Your dentist could be disciplined by their regulatory body which could include a heavy fine, suspension or even lose their license for engaging in this practice. Never participate in insurance fraud by asking and expecting your dental practitioner to waive your co-payment.

How do I know if my practitioner is operating legally in British Columbia?

For your treatments to be covered by Pacific Blue Cross, your practitioner must be registered with the appropriate regulatory college or association in the province where the service takes place. When an invoice is issued for the service rendered, a registration number must be printed on practitioner invoices. If you are unsure if your practitioner is registered in the Province of BC, please call our office or research your practitioner online. Your best bet is to seek a practitioner who bills us directly – this not only saves you from paying up front, but ensures that the practitioner has already been verified by us.

Members can submit tips to the Whistleblower Hotline at pbc-ethics.com or by calling 1 800 661-9675.


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 by:

Phone: 1.800 661-9675.
On-line: www.pbc-ethics.com

The Whistleblower 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 only.

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 law enforcement.

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