To protect the security of personal information, your Internet browser will need to be upgraded to access this website. Please ensure you use the latest version of:

Internet Explorer

Microsoft Edge

Mozilla Firefox

Google Chrome

Safari

The wait is over!

Our member site and app have undertaken a massive makeover to serve you better. To access the app, please uninstall and reinstall any versions older than 5.0.1 on Apple and 5.0.1 on Android.

How we manage fraud

We take benefits fraud and abuse very seriously. In order to protect your plan, your information and our reputation to the best of our ability, we follow a five-step process to manage fraud.

Some of our fraud management practices include

  • monitoring claim patterns,
  • running robust analytics processes to identify irregularities so we can focus on areas of greater risk,
  • conducting regular audits to ensure compliance with plan contracts and agreements,
  • terminating agreements and delisting providers,
  • filing official complaints with professional colleges and associations,
  • pursuing civil litigation and criminal prosecution where evidence indicates fraudulent activity has occurred, and
  • calling for restitution where warranted.

Prevent

  • Educating health care providers, plan members and plan sponsors on fraud.
  • Participating in industry and stakeholder engagement to share insights and collaborate on combating benefits fraud.
  • Providing plan design and management expertise, including fraud mitigation.
  • Managing a proprietary, real-time claims systems that incorporates hundreds of systems edits.
  • Continuous monitoring of claims behaviours for members, health care providers and groups.
  • Leveraging machine learning and advanced analytics to identify high-risk claiming behaviour.
  • Managing and responding to the fraud tip reporting hotline.

Detect

Investigate

  • Conducting risk-based pre-payment claims verification.
  • Conducting targeted member and provider audits for non-compliance.
  • Escalating incidents to a dedicated investigation team.
  • Terminate a plan member’s coverage.
  • Terminate agreements.
  • Delist health care providers.
  • File complaints to professional associations or colleges.
  • Pursue civil litigation and criminal prosecution.

Act

Learn

  • Implement any lessons learned.
  • Improve internal fraud management practices.