HomebusinesshealthAwards and RecognitionbusinesshealthResourcesBlog
The Callery Group
About UsOur ServicesContact Us

Crime Costs
5 scams that could be placing your benefits plan at risk

By many estimates, up to 10% of health-related insurance benefits are squandered through fraud. Putting the figure another way, the Canadian Group Insurance Brokers association says this crime accounted for up to $8 billion in healthcare spending in 2007 alone.

The victims of these crimes are not limited to faceless insurance companies. The cost of fraud can translate into higher service costs, lead to steeper insurance premiums, or sacrifice a plan’s available coverage.

It can even make it more difficult to access a service you need. There was a time, for example, when orthotics could be quickly prescribed to those who struggle with back problems. That process had to be tightened to include formal visits with a medical specialist like a chiropodist or podiatrist as well as a formal examination of your gait.

Unfortunately, thieves have been pretty creative when finding new ways to defraud these valuable programs. Consider these 5 scams that may be putting your coverage at risk:

1. Code breakers

There is no secret that some dental procedures cost more than others. But unscrupulous dental offices have been known to change the codes on their invoices, making it look like the bill for one procedure was actually linked to a different procedure covered by a benefits plan. A close look at the invoice for a new set of crowns, for example, may uncover the codes for a series of fillings; a simple procedure may be described as a complicated extraction.

2. The shoe sham

One Toronto chiropodist offered patients $150 gift certificates to a local sporting goods store, but issued receipts so the cost could be billed to insurance plans, according to a College of Chiropodists’ discipline decision. Patients who received “prescribed” Birkenstock sandals were handed receipts for custom-made orthotics.

It led to a massive cost for benefits providers. In one year alone, he purchased more than $323,000 in gift certificates for this purpose.

3. Bought benefits

Some fraudsters have been known to buy and sell benefits like commodities.

The crime works something like this: A scam artist buys a plan holder’s available coverage for pennies on the dollar. A massage therapist is then paid to issue a bogus receipt, which is then used to claim the maximum amount allowed under the benefits plan.

Plan holders who sell their policy numbers may pocket some short-term profits, but they will also be left exposed to any legitimate medical costs that emerge.

4. “Spa” treatments

In one report, CBC News uncovered spa owners who recorded esthetic treatments as therapeutic massage so the treatments would be covered by insurance plans.

5. Doctored receipts

Plan holders who have already claimed their “calendar year maximums” may be greeted by an offer to change the date on an invoice, to make it look like a procedure was completed in the following year.

It is not the only way that receipts have been doctored. Fraudsters have been known to apply the cost of one client’s procedure to another client’s benefits package, or even charge for services which were never actually performed at all.

Plan holders can help to protect their benefits plan from these scams by asking for detailed receipts which include exact amounts, descriptions of every treatment, and the date of the service. They can also report any suspected fraud through groups including the Canadian Health Care Anti-fraud Association, Ontario Ministry of Health, Workers Safety and Insurance Board, Insurance Bureau of Canada, police, or benefits providers.

For their part, employers can offer different tiers of coverage depending on an employee’s years of service. This will limit the exposure related to short-term employees who plan to defraud the programs as much as possible during their brief time on the payroll.

Unfortunately, these scams are difficult to track. Fraudulent invoices can slip through the cracks without being checked, as benefits providers look to process insurance claims as quickly as possible. And an increase in the number of invoices submitted through a benefits plan may simply indicate that employees are maximizing the value of their programs.

But a little education can educate employees about the true cost of the fraud which puts these programs at risk, and help them take a bite out of this growing and costly crime.

Top Tips:

  • Encourage employees to ask for detailed receipts for any healthcare services, itemizing every treatment as well as the proper date of service.
  • Use tip lines to report suspected cases of fraud.
  • Base the amount of coverage on an employee’s years of service. This will limit exposure to short-term employees who want to defraud plans for as much as possible before leaving the payroll.

The Buzz Bits
Miscellaneous links to interesting benefits information

Did you ever wonder what single thing can make the biggest difference to your health? Click on the following link offered by Dr. Mike Evans, a family physician at St. Michael's Hospital, to find out.
http://www.myfavouritemedicine.com/23-and-a-half-hours/

What plan sponsors need to know
http://www.chcaa.org/education/plansponsors.php

Protect your benefits plan from fraud
http://www.benefitscanada.com/benefits/health-benefits/protect-your-benefits-plan-from-fraud-27902

9 fraud prevention tips for benefits plan members
http://www.smallbizadvisor.ca/group-benefits/fraud-prevention-tips-for-benefits-plan-members-1118

Community Ethics, Big City Expertise

Subscribe to the Buzz Blog

Blog archive

Time To Get Ahead Of The Curve

"We've all been working from home for the last four months and now it looks like we're probably never going to go back to working in the office." It’s a statement I'm hearing every day, as more and more workplaces are discovering that working from home is working out better than anyone ever imagined. [more]

Hitting Reset On The Mindset

We can't afford to think "when this is over." We have a job to do and a chance to step up and really shine [more]

Working From Home

10 ways to communicate effectively in a working-from-home environment  [more]

Managing Paramedical Benefits

Think aboutwhy you offer paramedical benefits in order to manage them effectively  [more]

It's All About The Experience

I thought cell phone dependency was a cliche - until I lost mine far from home  [more]

What Happened When I Lost My Phone

I thought cell phone dependency was a cliche - until I lost mine far from home  [more]

"Mental Health" Doesn't Mean What it Used to Mean

We’re done admiring the problem, and it’s time to take some action  [more]

When There is No Return to Work

An Ontario court has set a limit on employers' return-to-work obligations  [more]

Rooting Out the Root Causes

When benefits fraud gets out of hand, it's a sign of big problems higher up  [more]

Four Key Gaps in Benefits Plans

Annual Sanofi survey zeros in on knowledge gaps in plan management [more]

How to Avoid Falling Through the Generation Gaps

Never mind "the older" and "the younger" generation – there are now five of them [more]

Predictive Analysis and Three Other Trends to Watch

Benefits and wellness programs are never going to be the same again [more]

Pharmacare: A Solution Looking for a Problem

Pharmacare would be such a good idea - if everybody wasn't already covered [more]

When the "Human Side" Gets Right in Your Face

A seriously injured client gives us a whole new perspective on resilience [more]

Is Virtual Health Care the New Must-Have Benefit?

In the age of the smart phone, do we really still need to line up and wait to talk to a doctor? [more]

Three Things I Learned from Doc Martin

When it comes to losing weight, there are a few basics you just can't get around [more]

Top 10 Take-Aways from a Crazy Busy Year

What we can learn from the biggest and most controversial issues we've looked at this year [more]

Engagement is the New Normal

What do employees really want from their jobs? [more]

10 Things You Need to Know about Travel Insurance

How to avoid making the mistakes that could cost you your insurance coverage [more]

How to Give First Aid for Mental Health

There's a new perspective on mental health at work, and it's a real eye-opener [more]

What Else Is In Bill 148 - And Why You Need to Know

There's a lot more to Bill 148 than minimum wage hikes and personal emergency leave [more]

The Next Big Thing in Benefits?

Major insurance providers are looking seriously at covering pharmacogenetic testing [more]

Will Cannabis Legalization Change Attitudes about Testing?

New legal limits for impairment may have a bigger impact than legalization [more]

Avoiding The Dreaded "Claim Rejected"

Benefits administrators are always caught in the middle when claims are rejected [more]

Big Data Takes On Benefits Fraud

Data analysis is starting to make a dent in many benefits fraud schemes [more]

The Chronic Pain Puzzle

Financial costs alone are higher than cancer, heart disease and HIV combined [more]

Financial Wellness: Why Money Management Counseling is Such a Good Idea

Debt counseling and money management education can make a big difference for employees [more]

The Next Big Thing: Mental Health Policy

It's time to get ahead of the curve on this one [more]

Unintended Lessons I've learned about Blogging so far

You never know what's going to happen when you click on a link [more]

Drugs, Alcohol and, Oh Yes, Marijuana

Changing times may require all of us to take a long hard look at our drug-and-alcohol policies [more]

Best Tips For Sleeping Well

If you're just not sleeping well, there are some pretty effective things you can do to make it better [more]

Survey Says: Wellness Programs Improve Overall Satisfaction

It seems that employees' satisfaction with wellness programs spills over into satisfaction with their benefits programs and their jobs in general [more]

Changes Coming to Personal Emergency Leave Laws

Amendments to the Employment Standards Act will significantly increase legally mandated employee leaves [more]

The Good News and the Bad News on Diabetes

We keep hearing about a "diabetes epidemic," but there are things we can do now to improve our odds of beating the statistics [more]

Who's Your "Broker" Working For?

In a world of brokers, agents, advisors and consultants, it's important to stay focused on who's really working for you [more]

The Secret to Really Good Workplace Wellness

Workplace wellness is a way to solve a lot of problems before they even come up [more]

Medical Marijuana - More Questions than Answers

A lack of medical consensus makes drug plan coverage of medical marijuana very difficult [more]

Pharmacogenomics Means Better Prescriptions

A simple DNA test can now help pinpoint which drugs are going to work best for you [more]

Why Airplanes Crash

What one successful CEO learned from air crash investigations – and how it all applies to managing any organization [more]

Not A Delicate Subject Anymore...

How to start the conversation about mental health in the workplace [more]

A Look Inside

There's more to this business that we usually talk about... [more]

Bio What-Now?

Get ready for "generic" biologics. [more]

What You Don't Want to Say to Your Doctor

There are some things that you want to explain to your doctor, and some things you really should stay away from. [more]

Your Dentist's Pet Peeve

Why you should know all the ins and outs of your dental insurance plan before you ever lean back in the chair and open wide [more]

About that Credit Card Travel Insurance

It may be of some value, especially if you have no pre-existing conditions, but you really need to read that fine print [more]

Right Drug, Right Time, Right Cost

Why you should work with your doctor, your pharmacist, and your drug plan to make sure you get optimal treatmenty [more]

Big Smiles

A focus on dental plans will ensure that everyone remains happy [more]

Your Doctor Doesn't Know Everything

When it comes to prescriptions, patients need to be part of the conversation [more]

Prescription for Disaster

Advances in pharmaceuticals are threatening your drug plan [more]

Sleep Easy

Conditions like sleep apnea can be treated, ensuring proper rest and productive days [more]

Easy as EAP

Formal support makes a big difference when employees face personal challenges [more]

Well Done

10 ways to develop an effective workplace wellness program [more]

Mind Matters

Businesses can't afford to ignore the mental health of their employees [more]

Brian's Story

Brian Callery is celebrating 40 years in our business. It's a commitment that makes a difference in his clients' businesses [more]

The Benefits to You

The same plans designed to protect employees will also offer advantages to employers [more]

Lawyer Up

There are legal ramifications around changing benefit plans - especially if an employee is being terminated [more]

Travel Trauma

Dream vacations can turn into nightmares when travel insurance claims are denied [more]

Evolution Solution

Evolving benefit plans will meet employee needs and support recruiting and retention efforts [more]

Plan & Predict

How rising paramedical claims, drug reforms, and other trends will affect your workplace benefits [more]

Who Benefits

Education makes the case for workplace benefit plans [more]

Season of Renewal

Important questions to ask your benefits advisor before inking a deal [more]

Preventive Measures

Paramedical services help keep employees healthy, on the job, and productive [more]

A Bounce in Their Step

Canada Rubber Group employees are embracing their new wellness program [more]

Business Benefits

Shandex Group and Indaco Manufacturing discuss the value of evolving employee benefits plans [more]

A New Mindset

Workplaces can't afford to ignore the mental health of employees [more]

Cost Cutters

10 cost-cutting strategies to protect your benefits plan [more]

Safe Travels

12 ways to protect yourself on your next vacation [more]

Breaking News

Learn from the mistakes of an AOL executive when discussing any changes to your benefits plans [more]

Watch the Gaps

Protect against turnover and lost opportunities by recognizing the generation gaps [more]

Generation Next

Generation Y represents the future of your business - and will see workplace benefits plans in a different way [more]

Absent Minded

Employers are paying the price for absenteeism, but it can be controlled [more]

Think Positive

Programs that build positive workplaces make business sense [more]

Back to School

8 important lessons your employees need to learn about benefits plans [more]

Find a Better Broker

6 questions you should ask anyone who wants to sell you a benefits plan [more]

Plan Your ROI

5 ways employee benefits plans can deliver a real Return on Investment [more]

The Benefit of Benefits

3 ways a benefits plan can improve your company's bottom line. [more]

A Healthy Dose of Information

5 questions for your pharmacist that might save your drug plan and your wallet. [more]

Claim Denied

Consider these 8 ways to avoid rejected benefit claims. [more]

Travel Planning

6 questions to ask before assuming you are protected by a group plan's travel insurance. [more]

Biologic Logic

Growing list of biologic drugs could bankrupt poorly protected drug plans. [more]

Smart Shopping

8 shopping habits that will protect your benefits plan. [more]

Tough Medicine

Employees will share more responsibilities and higher costs to sustain their benefits. [more]

Crime Costs

5 scams that could be placing your benefits plan at risk. [more]

A Prescription for Your Drug Plan

Skyrocketing drug prices may be threatening your benefits plan, but generic drugs offer a cure. [more]

Planes, Trains and Travel Insurance

The fine print in your travel insurance may leave you more exposed than you think. [more]

Healthy and Wealthy

5 steps to an employee wellness program that will generate real financial returns. [more]

Avoiding Burnout During Holiday Season

Education and Prevention can help control spiraling benefit costs. [more]

Sweat the Small Stuff

Protect your staff by avoiding these common "paperwork" mistakes by administrators. [more]



Services Personal Services Corporate Services