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Protecting your plan from benefits fraud. We all have a part to play.

With health benefits fraud becoming increasingly sophisticated, you can help to control plan costs by being a more informed consumer and knowing what to look for to detect fraudulent schemes.

What do we mean by “benefits fraud”? Some examples to think about.

Benefits fraud refers to any abuse, misuse, or over-utilization of the plan as well as inappropriate health provider billing practices – whether intentional or not. A benefits plan can be affected by a variety of different forms of fraud by both plan members and health services providers. Fraud can include things such as:

  • Receiving products & services not covered and claiming them as different covered services and products. Example: claiming spa and facials as massage, sunglasses as prescription sunglasses, or regular shoes as orthotics
  • Accepting incentives or gifts from providers. Examples: getting free shoes with orthotics, or being offered cash or other incentives to gain new patients or in exchange for your policy information
  • Overbilling with the goal of getting extra money. Examples: a provider charging $100 for a treatment but issuing a receipt for $200, or submitting a full claim for the same service to multiple insurers to double your reimbursement
  • Receiving covered products unnecessarily. Example: getting orthotics every two years, but not using them
  • Transferring coverage between different covered services. Example: if insurance only covers a 30-minute massage and a health provider bills for one session of physiotherapy and one session of massage on different days so you are covered for a one-hour massage
  • Transferring coverage between covered members. Example: claiming a treatment or service under a dependent’s benefit coverage when you used the treatment or service yourself
  • Letting someone not covered (mostly friends and relatives) use your insurance benefits. Example: letting an un-insured family member or friend use your name and claim under your insurance.

Benefits fraud is a real crime with consequences that can impact you and your family such as:

  • Loss of benefits
  • Loss of job
  • Increase in premiums
  • Criminal record
  • Jail time & fines

Health providers that commit fraud are at risk of losing their license to practice, as well as jail time, fines, and a criminal record.

To learn more about fraud, visit Fraudisfraud.ca.

Stay a step ahead. What you need to know.

Learning what benefits fraud looks like will help you to prevent it. Check out these helpful tips.

Know the signs
  • Protect your GSC ID number. Never agree to sign a blank claim form. You should always verify what you are signing and only sign a claim form on the date that the service/product is received or picked up.
  • Accept only those services and products that are medically necessary and will use. Don’t fill a prescription if you don’t intend to take the medication.
  • Watch out for health providers requesting a list of your covered benefits and the plan maximums. They may use the information to charge for services or products you never received or may encourage you to get products and services you don’t need
  • Be aware of pressure for you to claim products or services that are not eligible benefits under your plan as different products or services that are eligible
  • Don’t include incorrect or misleading information on a claim, even if others are encouraging you to do so
  • Never accept cash or other incentives in exchange for your GSC ID number or plan information
  • If you get supplies automatically on a monthly basis, be sure you still need the items or are even using them
Be a smart consumer
  • Know your benefits plan and the limits of your coverage. Always ask how much is being billed to your benefit plan.
  • Read your Explanation of Benefits statement like you would your credit card statement – question services or products you don’t recognize. If your provider submits your claim directly to GSC, then you won’t receive a claim statement from us. Visit ‘Claims Information’ via GSC’s Plan Member Online Services for a look at claims billed on your behalf.
  • Make sure your health care practitioners are licensed with the appropriate regulatory agency or association.
  • Complete the claim audit questionnaires when you get them. These help us protect all of our plan members and their benefit plans from abuse, misuse and overuse.
  • Sign the "Release of Information Authorization Form" when requested. This gives us permission to review your claims information to make sure claims are appropriately and properly submitted on your behalf.
Choose your health provider carefully

To ensure plan members receive appropriate treatment, GSC requires that paramedical health practitioners must:

  • Be licensed with the appropriate provincial regulatory agency or association
  • Operate within their scope of practice

To check whether your provider has the proper credentials, you can use the “Find a Provider” tool on Plan Member Online Services or on the GSC on the Go app. Our database contains only health care providers who meet GSC’s standards for reliability and are in good standing with their applicable regulatory agency or professional association.

When visiting a health care provider, don’t be afraid to ask for the name of the person who will be providing the service to you and look for the health provider’s license – it should be on display, and if it’s not, you can ask to see it.

Remember, GSC has a variety of different tools to prevent and detect fraudulent activity from providers (and plan members). GSC’s Fraud Prevention Program involves a team dedicated to analyzing claims data and watching for unusual claiming patterns or anything else that stands out as odd. To do this we will periodically audit claims. If inappropriate claiming behaviour is suspected, we may need to take extra steps when we adjudicate and pay claims.

Suspect fraud? Get in touch.

If you suspect fraud or the possible abuse of your benefits plan, your concerns can be reported anonymously by calling toll-free 1.800.265.5615 ext. 6921 or 1.888.711.1119 and asking for our Confidential TIPS Hotline. You can also email us at bmis@greenshield.ca.