Having access to workplace benefits is a wonderful perk - but the system is vulnerable to misuse, creating great costs for employers that affect all employees.
The costs to businesses of falsified or inflated workplace insurance claims can run into the millions of dollars, raising employee premiums and needlessly tying up corporate resources, warns Joel Alleyne, executive director of the Canadian Health Care Anti-fraud Association.
Benefits fraud comes in several forms, including clinics billing for services not actually performed, providing unnecessary treatments, billing for excessive time or higher priced services, and simply falsifying invoices.
For their part, unscrupulous workers alter documents, make false claims, return products for refunds after receiving payment from the insurance company, swap benefit cards amongst family and friends, and forge documents, Alleyne notes.
Counterfeit Claims Scheme
For example, one group of employees was caught manufacturing claims for a number of people participating in their company plan.
Using little more than Photoshop, a scanner and a colour printer, the crew was able to create facsimiles of legitimate claims that looked realistic enough to dupe claims adjudicators – who process hundreds of claims each day.
The scheme’s ringleader recruited several plan members, convincing them to submit these false claims and then split the proceeds. Once caught, the sanctions were significant.
Phantom Family Members
In another case, an employee was caught manufacturing claims for a daughter that simply didn’t exist. Ironically, after being fired over this, she sued her employer for wrongful dismissal, arguing that the offence didn’t warrant such punishment.
Several years earlier, a “phantom” dependant was mistakenly included in her benefits profile. Realizing this, she falsified documents and submitted several claims in the name of a non-existent daughter.
The claims were approved at first, but the insurance carrier subsequently contacted the woman to verify the daughter’s eligibility – which she confirmed, even though the girl didn’t exist.
Further investigation revealed that she had also submitted falsified claims in the name of her son, who actually did exist.
Not only did she lose her job over the fraud, but her claims for both wrongful dismissal and damages under the Ontario Human Rights Act were rejected and she was ordered to reimburse her former employer’s legal costs.
How to Protect Yourself
Be sure to protect yourself, warns Alleyne, who has compiled a list of do’s and don’ts to help employees guard their health benefits.
- Do protect both your provincial and workplace benefits cards. When someone else uses these without your knowledge, your health records will be corrupted, affecting your insurability.
- Do check the receipts and explanations of the benefits you receive for products or services. Make sure these accurately reflect what was received and report any discrepancies.
- Do be suspicious of providers who routinely waive your co-payment or deductible.
- Do be vigilant. Watch for others abusing your company's health plan and report these abuses to Human Resources or your insurer on their anonymous tip line.
- Don’t sign your name to blank claims forms. These allow others to use you as a patsy for fraudulent activities.
- Do ask for copies of any claims forms that you do sign.
- Don’t let others use your health spending account. These are your funds alone.