Understanding insurance fraud and abuse and what to do about it
- What is insurance fraud and abuse?
- Who commits insurance fraud?
- How does insurance fraud affect you?
- What can you do to protect yourself from fraud?
- How do I report suspected fraud or abuse
- Are calls to the fraud hotline recorded?
- What happens to the person being reported?
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What is insurance fraud and abuse?
Insurance fraud is the intent to obtain reimbursement for claimable goods
or services that were neither received nor provided. Examples of insurance fraud
are:
- Misrepresenting items supplied on receipts
- Member returning items after reimbursement and not refunding PBC
- Submitting claims for services not rendered
- Altering receipts
Insurance abuse is any actions that use the benefit plan in a way that is
contrary to the intended purpose of the benefit, which results in unnecessary cost
to the plan. Examples of insurance abuse are:
- Providing medically unnecessary treatments
- Excessive use of benefits
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Who commits insurance fraud?
Pacific Blue Cross believes that the vast majority of our members, providers, and
groups are honest; however, there are a small percentage of people who will engage
in fraud and abuse. Anyone that has access to your personal benefit information
can commit insurance fraud or abuse.
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How does insurance fraud affect you?
Insurance fraud and abuse may reduce the member's benefits and in some cases, high
fraud risk benefits may be eliminated by the employer/plan sponsor altogether because
of the financial risk.
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What can you do to protect yourself from fraud?
Members can protect themselves and others from health insurance fraud and
abuse by taking these steps:
- Keep your PBC ID card and information in a safe place and report lost or stolen
cards to your employer or PBC.
- Monitor your claims submitted by the provider. You can review your claims information
via CARESnet, Pacific Blue Cross' online access to claims and benefit information
for members. (pac.bluecross.ca)
- Never allow anyone else to use your PBC ID card.
- Contact PBC if you suspect that someone is committing a fraud against your plan.
Providers can protect their business, as well as their patients/customers
from health insurance fraud and abuse by taking these steps:
- Verify that the patient you are about to provide services for is an actual PBC member
by requesting picture identification
- Ensure receipts are issued for exactly what was provided.
- Validate patient chart information to remittance statements for accuracy.
- Contact PBC if you feel that someone is falsely using a PBC Health and Dental card
or is abusing the plan.
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How do I report suspected fraud or abuse?
To report any fraud or abuse you can contact our confidential Whistleblower Hotline
by:
Phone: 1.800 661-9675.
On-line: www.pbc-ethics.com
The Whistleblower Hotline is administered by CANPRO HRservice's Confidence Line™,
an independent third party to ensure the strictest confidence and you are not required
to provide your identity should you wish to remain anonymous. You will be issued
a unique reference number, which can be used to provide additional information anonymously.
The hotline is available 24/7.
Alternatively you can contact us by mail:
Pacific Blue Cross
Attn: Audit Services
PO Box 7000
Vancouver, BC V6B 4E1
Pacific Blue Cross' Audit Services will investigate all allegations of fraud and
abuse. The information we receive will be kept confidential to the extent possible.
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Are calls to the fraud hotline recorded?
Yes, the calls are recorded. CANPRO HRservice's advises every caller that the call
is recorded for accuracy purposes and is strictly intended for the use of ConfidenceLine
only.
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What happens to the person being reported?
If the allegation is substantiated, we will take the appropriate action. This may
include but not limited to recovery of funds, termination from the plan or notifying
law enforcement.
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