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What Does Benefits Fraud Look Like?

Posted by Gordon R. Hart

Aug 9th, 2019

What Does Benefits Fraud Look Like?

People you may not expect, like health and dental service providers, friends, family members, and colleagues, could all lead you to commit benefits fraud. It is possible to become involved in it because it was suggested by someone you trust. It’s important to learn what it looks like so you can help prevent it.

Benefits fraud occurs when the plan member intentionally submits false or misleading information to the plan provider for the purpose of financial gain. This fraud can be perpetrated by the plan member, the health or dental service provider, or both.

How can fraud be deducted in a number of ways,

• Report by a plan member

• Employer reviews of consumption with advisor

• Sophisticated technology of the providers that can detect unusual claiming patterns and can flag suspicious claims

• Random audits of member claims

• Provider cooperation on investigations of fraudulent activity

The immediate consequences of benefits fraud can include a loss or reduction in the benefits coverage, loss of employment, a criminal record, fines and jail time. Sadly, research* shows that 75% of insured Canadians surveyed think that the only consequence of benefits fraud is that premiums will go up, and only 25% believe they could lose their jobs.

Learning how to recognize benefits fraud is the first step toward preventing it. Some warnings signs include,

• Feeling pressured by your health or dental service provider to get unnecessary products or procedures

• Being encouraged to reclassify products or services from ineligible services to those that are eligible

• Health or dental services providers who are more concerned about your coverage than treating you as a patient

• Being asked to sign a blank form

• Being charged for health or dental services that you did not receive

• Being offered cash or other incentives in exchange for your coverage information


To defend against fraud,

• Familiarize yourself with your benefits plan coverage and limits

• Keep your benefits plan access information safe and do not lend your card(s) to anyone

• Be sure you understand the treatments, services and products being prescribed to you – ask questions!

• Check that the explanation of benefits and receipts provided by the provider contain accurate information about the services or products you received

If you suspect your health or dental service provider or coworkers are encouraging you to submit a fraudulent claim, or something just doesn’t feel right, report it to your employer or insurance provider immediately. You can also report benefits fraud anonymously here: report benefits fraud.

*CLHIA Anti-Fraud Campaign Research Report, Environics Research Group, March 2018

What Does Benefits Fraud Look Like?

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