Benefits fraud

Member fraud occurs when the benefit plan member misrepresents the service or product they claimed in any way. On occasion, people may commit fraud unintentionally. However, even unintentional fraud is illegal and may carry serious penalties.

Here are some forms of member fraud to watch out for:

• Services not received—submitting for products or services not actually provided.
• Substitutions—substituting actual services or products received that are not covered for ones that are. For example, purchasing non-prescription sunglasses and claiming them as prescription.
• Identity sharing—sharing your coverage or ID number.
• Forgery—creating, forging or altering receipts.
• Missed or cancelled—submitting claims for missed or cancelled appointments.
• Double doctoring—going from one prescriber to another in order to obtain multiple prescriptions for the same product.
• Switching the claimant—claiming under another plan member’s name when you have reached the benefit type maximum. For example, claiming a teeth cleaning under your spouse’s ID number.
• Accepting incentives—free gifts (gift cards, cash, material items), when purchasing a product or service, can be used to inflate the price of the product or service.

How can you help prevent member fraud?

Protect your information and ID number.

Never share your policy number or other benefits information, and make sure your health care provider verifies your identity during appointments.

Monitor and submit accurate claims.

Always pay claims in full before submitting, and if your provider submits on your behalf, make sure you receive a statement of what was claimed.

Double check your information.

When entering a claim, make sure all the information you entered is correct before hitting submit. This will help you avoid unintentionally committing benefits fraud.

Keep your receipts.

Make sure all receipts contain the correct name, date and benefit type. Keep receipts for at least one year.

Report suspicious activity.

If you suspect benefits fraud from a plan member or health care provider, report it to Alberta Blue Cross^®.

Provider or retailer fraud occurs when a health care service or product provider misrepresents a claim, deceives a customer or deceives a health plan provider in order to receive a greater reimbursement.

Here are some forms of provider fraud to watch out for:

• Forgery—creating, forging or altering receipts.
• Switching the claimant—claiming under another plan member’s name when the patient has reached their benefit type maximum.
• Services not received—submitting a claim for products or services not actually provided.
• Claim inflation—claiming for a more expensive service than the service that was actually provided.
• Substitutions—substituting actual services or products that are not covered for ones that are.
• Unbundling—claiming separately for procedures that are actually part of a single procedure.
• Masquerading as health care professionals—delivering health care services without proper credentials.
• Providing incentives—providing purchase incentives such as gift cards, cash, material items or a point system.

How can you help prevent provider fraud?

Ensure receipts are accurate.

Make sure all receipts contain the correct name, date, charge and benefit type. Ensure receipts and invoices are not

• created for a service or product not yet received,
• billed or submitted over multiple days,
• submitted for missed or cancelled appointments, or
• submitted for substituted products or services.

Maintain documentation.

Keep charts, records and documentation to support claims. Retain claim records for a minimum of two years or as outlined by applicable professional regulations.

Follow reimbursement guidelines.

For plan member reimbursement claims, do not obtain a signed blank claim form, complete a claim form or submit a claim form on behalf of the plan member. If you must submit a claim on a patient’s behalf, verify their identity through a form of photo identification and their Alberta Blue Cross^® ID card.

Avoid incentives.

Do not provide a plan member with purchase incentives such as gift cards, cash or material items. This includes providing incentives through a finance company associated with the provider.

Maintain qualifications.

Be qualified and licensed. Operate within the principles of a governing professional college and association as recognized by Alberta Blue Cross^® and operate within the laws of the province where the services are delivered.

Report suspicious activity.

If you suspect benefits fraud from a plan member or health care provider, report it to Alberta Blue Cross^®.

Collusion occurs when a plan member and health care provider or retailer work together to commit fraud. These crimes are usually committed by members and health care providers from the same community.

Here are some forms of collusion to watch out for:

• False submissions—submitting claims for missed or cancelled appointments.
• Claim inflation—claiming for a more expensive service than the service that was actually provided.
• Misrepresenting services—submitting claims for services or products not offered.
• Switching the claimant—claiming under another plan member’s name when another plan member has reached their benefit type maximum.
• Incentives—submitting a receipt for products or services not provided while receiving or offering in-store credit for products or services that are not covered by the benefit plan. In some cases, gifts may be provided by inflating the price of the product or service.

How can you help prevent collusion?

Ensure accurate receipts.

Make sure all receipts contain the correct name, date, charge and benefit type. Ensure receipts and invoices are not

• created for a service or product not yet received,
• billed or submitted over multiple days,
• submitted for missed or cancelled appointments, or
• submitted for substituted products or services.

Avoid incentives.

Do not provide or accept incentives such as gift cards, cash or material items. This includes providing incentives through a finance company associated with the provider.

Keep documentation.

Keep charts, records and documentation to support claims.

Maintain professionalism.

Operate within the principles of a governing professional college and association as recognized by Alberta Blue Cross^® and operate within the laws of the province where the services are delivered.

Report suspicious activity.

If you suspect benefits fraud from a plan member or health care provider, report it to Alberta Blue Cross^®.