Have you witnessed benefits fraud in your workplace?

Benefits fraud could result in jail time
Benefits fraud could result in jail time

Recently, the Toronto Transit Commission was rocked by a massive benefits fraud case that saw 53 employees leave the organization amid an ongoing probe.

In the TTC case, a health-care service provider, Healthy Fit, was billed for services rendered, but no actual services were provided. The owner of the business and 10 TTC employees were charged with fraud.

The owner received two years in jail for his role, and a total of 223 workers have left so far, in relation to the case.

The organization is also suing Manulife for $5 million in damages, for what it alleged is the insurer’s role in not having a robust fraud management protocol in place.

But just how widespread is this problem?

According to Karen Voin, vice-president of group benefits and anti-fraud at the Canadian Life and Health Insurance Association (CLHIA), the problem in Canada costs “hundreds of millions” each year out of the estimated $32 billion in annual benefits provided each year.

“In North America alone, it is estimated that two to 10 per cent of all healthcare dollars are lost to fraud. This means higher costs for everyone,” according to the CLHIA website. This translates to about $1.2 billion and $6 billion every year.

This means that the price consumers pay for benefits will always rise to cover the cost: we all pay for fraud.

Insurance company Great-West Life defines fraud as: “intentionally providing false information or withholding information to ensure the payment of a claim. Insurance fraud can take many forms, from backdating a disability claim to submitting a fictitious or inflated medical or dental claim.”

PEO Canada, an HR outsource provider, has some common-sense tips for health benefits’ consumers on its web site so people are able to easily identify potential frauds: Keep track of all receipts from service providers, report any discrepancies on your own personal statements, report any providers who “try to persuade you to misuse your benefits plan,” and especially, “Do not sign blank insurance forms or provide blanket authorization to bill for services as these can be used to submit fraudulent claims.”

As well, iA Financial Group, which offers various health insurance products, advises consumers to “Ensure that the treatments you receive are medically necessary and have been recommended for you and/or your family members,” and says, “Do not give anyone your policy and certificate numbers or any other information about your benefit plan. Be wary of aggressive marketing programs.”

If you suspect fraud and wish to report it, there are two places in Canada to go: https://www.clhia.ca/ and http://www.antifraudcentre-centreantifraude.ca/index-eng.htm

The message is if you participate in fraud, it could come back to bite you in the wallet or even worse, you could end up in jail!

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