March is Fraud Prevention Month. In group insurance, fraud and abuse represent 2 to 10% of healthcare costs¹. It is important to note that group insurance premiums are calculated based on group consumption, among other things. When benefits are paid following the submission of inappropriate claims, the premiums may be increased.
This is a growing problem, and La Capitale is devoting a lot of effort to preventing this problem. To ensure the longevity of your group insurance plan and protect yourself from fraud, there are certain habits that you can adopt.
What is fraud?
Fraud is any deliberate action that enables individual insureds or suppliers to obtain a reimbursement of expenses to which they are not entitled.
A concrete example of fraud
Julie has been working out at the gym for a few months. To improve her performance, she decides to consult with a healthcare professional. During the first visit, he makes her the following offer:
“You know, Julie, since my fees are covered by your group insurance plan, we can include your gym membership as an eligible service. I can give you receipts for your insurance company, and that will save you a lot of money.”
If Julie accepts this offer, she and the healthcare professional are committing fraud.
A few tips on how to prevent fraud
Protect your confidential information
By doing so, you prevent others from obtaining a refund in your name. If you use an online reimbursement service, use a password that’s difficult to hack, and change it regularly. If you have a service card, make sure it is not used by anyone other than you and your dependents. Also refrain from providing too much information about your insurance coverage. Fraudsters are on the lookout for generous insurance plans.
Familiarize yourself with the provisions of your group insurance plan
When enrolling in your group plan, you obtain access to a paper or electronic version of your detailed insurance booklet. Read it carefully to ensure you understand about the types of coverage and plan maximums. The booklet will indicate the types of expenses covered and how to submit a claim.
Check your receipts
Make sure your receipts accurately reflect the services you received or the supplies you obtained. Also ensure that the amount is correct and that the receipt was issued by the supplier that rendered the service. If any information seems inaccurate, don’t hesitate to mention it to your supplier. You should also keep your original receipts, or a copy of them, for a 12-month period following the claim date.
Don’t sign a claim form in advance or a blank form
Sign one claim form at a time and do so only once it has been completed. By proceeding in this manner, you ensure that your healthcare professional does not add any undesired information after you have signed the form.
Be mindful of alarm signals
Certain suppliers may suggest treatment or equipment that your physician or healthcare professional has not recommended. Also be mistrustful of boutiques with unusually attractive deals or high costs.
Report any situation that appears suspicious
To report suspicious situations, call us toll free at 1 800 463-4856 or send us an email at firstname.lastname@example.org. You can also contact us if you would like to have confirmation that your supplier is acting in accordance with the eligibility criteria of your plan.