PROTECTING YOUR
EMPLOYEE BENEFITS PLAN
FROM MISUSE AND ABUSE
You wouldn’t pay a credit card bill for something you did not
buy, would you? We think the same logic applies to your
employee benefits plans—no one should pay for bogus claims.
Like everything of value, your employee benefits plan deserves to be well-protected.
With Empire Life on your team, you don’t have to worry whether everyone’s playing
by the rules. We do that for you. That’s because benefits fraud hurts everyone and can
result in higher premiums. We’re committed to helping you keep your benefits
plan sustainable—by watching out for misuse and abuse.
Generally, most people submit their claims in good faith. Unfortunately, some people
see their benefits plans as a source of extra income to be tapped. Our specialized claims
investigation unit has the tools and training to watch for:
• Healthcare providers who submit false claims. Some submit treatments they never
performed; others inflate the cost and complexity of their work—or prolong the
duration of treatments unnecessarily. Some bill a service as something else, as a
way to get around eligibility rules and maximums.
• Employees who misuse their benefits. Some fabricate receipts for services they never
had while others adjust the amount to claim more money. Still others avail themselves
of services they don’t need, out of a misplaced sense of entitlement. When it comes
to disability claims, some people double dip: earning unclaimed income under the
table while collecting costly benefits.
• Plan sponsors who collude with providers or employees to make false claims.
It’s rare, but it happens.
Our staff is well trained to identify claims that don’t look right. In addition to the
in-house training we provide, team members bring knowledge and experience from
their fields of expertise—medicine, nursing, dental hygiene, for example. Everyone is
required to stay up-to-date with emerging trends through conferences and seminars. We
also participate in knowledge-sharing organized by the Canadian Health Care Anti-fraud
Association—of which Empire Life is a founding member. We work with their investigators
and with appropriate law enforcement agencies to stay ahead of schemes that can harm
employee benefits plans.
1
Canadian Health Care Anti-fraud Association, 2013
It’s estimated that
$12 billion
is lost to healthcare
fraud each year1
ROBUST CONTROLS
The table below sets out some of the ways we scrutinize and validate claims.
Healthcare
Life
Disability
Validate providers’ credentials
Validate the proof of death
documentation
Interview the employee
Verify that services charged are in line
with best practices
Call specialists and regulatory bodies
to understand treatment protocols
Manage claims per coordination of
benefits rules
Check for irregular or suspicious
claiming patterns
Interview the employer
Check the beneficiary identity (and
verify that they were not charged with Validate medical conditions,
diagnoses, tests and treatments,
or convicted of being involved in the
through our in-house medical
circumstances of the death)
consultants
Gather supporting documentation
Contact the treating physician, when
needed, to discuss the employee’s
condition and treatment plan
Help resolve personal or workplace
issues that may be affecting
return-to-work
Scrutinize pre-programmed areas of
focus, where we identify a problem
provider or new scam
Arrange home visits, worksite visits,
and third party assessments
Verify employees’ (and/or dependants’) identity
Check that people being claimed for are eligible
Assess claims against plan design
Audit random sample of claims, post-payment for quality assurance
Our robust online system detects irregular or suspicious claiming patterns and dynamically
scrutinizes pre-programmed areas of focus, such as problem providers and new schemes.
Unlike other approaches that pay irregular-looking claims and then route them for review,
our system routes these claims for review first. We have confidence that we get it right
the first time and avoid paying for things that aren’t covered. This helps avoid time wasting
follow-ups and efforts to recoup incorrectly paid monies.
Our intelligent system of checks, reviews and investigation does an excellent job of detecting and
preventing abuse. We also conduct daily and quarterly audits to ensure quality control on our part
and to detect abuse.
If you suspect suspicious claim activity or have any questions about fraud and abuse, contact our
confidential tip line at 1 800 267-0215, menu option #4, or by email at
[email protected].. We’re here to help.
TIPS FOR CUSTOMERS
You wouldn’t pay a credit card bill for something you did not buy, would
you? We think the same logic applies to your employee benefits plans—
no one should pay for bogus claims. Left unchecked, fraud hurts everyone
and can ultimately make a plan unsustainable. That’s not good for anyone.
You play an important role in preventing benefits plan fraud and abuse.
Here’s what you can do.
Treat benefits fraud and claim abuse as a serious matter
• It’s estimated that $12 billion is lost to healthcare fraud each year1
• Benefits fraud is a serious offence – offenders are stealing from your plan
Increase awareness – communicate with your employees
• See that everyone receives a copy of their benefit booklet so they are familiar with
what their plan covers
• Educate employees about their role in preventing misuse, abuse, and fraud. Explain
how it can drive up costs and could force you to reduce coverage
• Encourage your employees to be a partner in maintaining the health of their benefits
plan through consistent communication and tips
Collaborate with us on claim audits
Claim audits help prevent and detect benefits fraud and claim abuse.
Talk to your Advisor about benefits plan design options that can help prevent
inappropriate claims. Examples of things to consider include:
• Dollar maximums on services that are commonly abused, such as medical supplies,
orthotics, and massage therapy
• Combined maximums to decrease overall risk
• Co-pays to encourage employees to use their benefits wisely
A Healthcare Spending Account (HCSA) to limit expenses but still offer flexibility
If you suspect suspicious claim activity or have any questions about fraud
and abuse, contact our confidential tip line at 1 800 267-0215, menu
option #4, or by email at [email protected]. We’re here to help.
1
Canadian Health Care Anti-fraud Association, 2013
TIPS FOR EMPLOYEES
You wouldn’t pay a credit card bill for something you did not buy, would
you? We think the same logic applies to your employee benefits plans—
no one should pay for bogus claims. Left unchecked, fraud hurts
everyone and can ultimately make a plan unsustainable.
That’s not good for anyone.
You can help protect your employee benefits plan from fraud and abuse. Here’s how:
• Review your employee benefit booklet to understand your coverage.
• Keep your benefits information confidential.
• Ensure your health care provider has legitimate credentials.
• Submit claims online whenever possible – there are lots of checks and balances in
place to protect you and your benefits.
• Check your receipts and explanation of benefits. Report discrepancies between
services/products received and what was billed.
• Never pre-sign blank claim forms.
• Understand the need for claim audits and actively participate in them.
• Report suspicious activity to your employer or to Empire Life immediately.
If you suspect suspicious claim activity or have any questions about fraud
or abuse, contact our confidential tip line at 1 800 267-0215, menu option
#4, or by email at [email protected]. We’re here to help.
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www.empire.ca [email protected]
GRP-1290-EN-06/16