Benefits Fraud: What is it and why it matters

Akhil Pandit PautraSenior Pharmacy Audit Manager for Express Scripts Canada explains this important issue and how you can help

Every year, insurance companies and healthcare benefit providers lose hundreds of millions of dollars because of fraudulent claims for health benefits. This cost isn’t just borne by providers, however, the negative impacts trickle down to employers that provide benefits as well as their employees, the ultimate intended beneficiaries. 

Benefits fraud can take shape in many different forms. These illegitimate scenarios include fraudsters:

  • billing for services that never took place or different than those provided;
  • submitting the same claim to multiple insurers;
  • using benefits to purchase items not covered such as non-prescription sunglasses and submitting the claim as prescription eyeglasses;
  • transferring unused benefits to others, such as using a dependent’s unused benefits to cover another’s health or dental expenses;
  • claiming prescription drugs on behalf of others not covered under your plan.

An individual can even be involved in benefits fraud without knowing it. For example, when a health service provider falsifies a patient’s medical condition reports and/or provides unnecessary treatment or service. Similarly, such an unscrupulous service provider may bill an insurer for services that were never provided.

Why should Canadians care about benefits fraud?

Canadians enjoy one of the most comprehensive systems of healthcare benefits in the world. To ensure we continue to enjoy this privilege, it is important to understand that providing health benefits comes at a significant cost to employers. Many struggle to keep their plans sustainable. In fact, Canada’s private sector spends about $60 billion annually on health benefits.

One of the key ways to ensure sustainability of our benefits system is to curb fraud. Here are simple ways you can help:

  • Protect your personal information including your signature, health card and drug plan numbers.
  • Don’t give anyone your drug card for any reason.
  • Check your receipts and Explanation of Benefits (EOB) statements.
  • Request your pharmacy drug claims history annually.
  • Never sign a blank insurance claim form or give blanket authorization to a provider.
  • If you are a prescriber, protect your prescription pad.
  • Check all claims submitted in your name (whether as a patient or service provider).
  • If you suspect fraud, contact your insurer.

At Express Scripts Canada (ESC), we’re committed to identifying fraud and recuperating waste to ensure healthcare dollars are only used for legitimate health claims. That’s why we developed the ESC Fraud, Waste and Abuse program.

This innovative program is designed to help ensure plan sponsors don’t incur unauthorized costs by verifying that only legitimate claims are paid. ESC’s Fraud, Waste and Abuse program provides an ongoing proactive review of all plan claims using advanced data analytics, audits, investigations and detailed reporting.

ESC uses risk scores to identify behaviour patterns, which may be indicators of fraud, waste and abuse such as short days’ supply, multiple drugs per claimant and volume spikes month over month. This results in earlier detection of fraud, and faster resolution times, before volumes become significant. This program effectively detects fraud and seeks to recover money that would otherwise be lost to fraudulent claims. In 2020, we recovered more than $13 million for our clients.

ESC plan sponsors are encouraged to learn more about our Fraud, Waste and Abuse program by speaking with their account manager. ESC Pharmacy patients are also encouraged to get involved by learning more about healthcare fraud and reviewing their claim records to ensure that fees for medications and services align with those that have been legitimately provided.

Together, we can help stop benefits fraud, and ensure our benefit plans continue to provide us with the healthcare we need.