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Health care fraud is a national problem that impacts all of us and costs billions of dollars every year in Canada. As a medical supply provider, you play a critical role in preventing fraud to protect your customers and your business.
At a broad level, health care benefit plan fraud is an intentional misrepresentation or deception resulting in greater reimbursement. For medical supply providers, it goes further—it is also an act that goes against acceptable business practices and can look like any of the following:
Where investigations uncover fraud, plan abuse, unethical or illegal activity, action needs to be taken. We will pursue financial recoveries, cancellation of your provider eligibility status with Alberta Blue Cross, civil action and, potentially, criminal complaints.
Ensure authenticity—receipts must constitute an accurate account of products and services rendered and must show the actual amount paid by the member. Also, the name of the person receiving the product must be the name shown on the receipt.
Follow proper payment processes—do not obtain a signed blank claim form, complete a paper claim form or submit a claim form on behalf of the member. Plan members must pay for their products in full and submit their own claims forms.
Know what to avoid—be sure to understand what fraud is and what you must avoid. Do not substitute products and do not provide members with purchase incentives, including providing incentives through a finance company associated to you.
Keep in mind footwear coverage plan rules—Alberta Blue Cross does not provide coverage for stock item (off-the-shelf) footwear. We cover custom made orthopedic shoes and/or the cost of the adjustment to stock item footwear but not the cost of the stock item footwear itself. Should a patient require footwear for their orthotics, the footwear should be itemized separately on the invoice.
Report suspicious activity—If you suspect any suspicious activity from a plan member or a health care provider, please report it immediately by calling the Alberta Blue Cross Fraud, Privacy and Ethics Reporting Service hotline toll free at 1-866-441-8477 or fill out a report online. All information will be kept strictly confidential.