Each year, an estimated $5-billion is lost in Canada to health care benefits fraud and abuse.
What is Benefits Fraud?
Benefits fraud is an intentional deception or misrepresentation, by an individual or entity, in respect of a claim that results in payment for an ineligible benefit under the benefit plan.
What is Benefits Abuse?
Benefits abuse occurs from practices that, although not usually considered fraudulent, are inconsistent with accepted, sound, medical, dental, or business practices. Examples of abuse include overtreatment, excessive billing, and billing for services that are not medically necessary.
Why do benefits fraud and benefits abuse matter to you?
Benefits fraud and benefits abuse can have a direct impact on your benefits coverage. When fraud and abuse occurs, coverage levels can be at risk because UBC is required to pay more for benefits coverage.
Here are some tips to help protect you against benefits fraud/abuse:
- Keep your benefits information confidential. Your benefits information is valuable. Keep your drug card and certificate/member ID confidential and in a secure place.
- Submit claims online whenever possible. Online claims submission and direct deposit is the most secure form of claims processing (using mysunlife.ca or Sun Life’s mobile app). Remember to keep your access ID and password confidential, even from your service provider.
- Check your receipts. Ensure your receipts are correct and reflect the services you actually received. If your provider submits claims electronically for you, cross-check your copy of this information with the claim statement you get from Sun Life to confirm they both reflect what you actually received.
- Never sign claims forms in advance. Sign one completed claim form at a time – never pre-sign blank forms.
- Report suspicious activity. If you are suspicious of any activity or request from a service provider or medical equipment supplier – such as actions that provide little or no benefit to you but maximize payments to the provider or supplier based on your coverage – please call Sun Life’s Fraud Hotline, toll free at 1-888-882-2221. Your confidentiality will be protected.
Tips for Preventing Fraud
Know your plan. Understand the treatments, products, medications, and services that are covered by your plan – and the limits that apply. Ask your health professional providing the service any questions if you’re unclear about their specific services.
Don’t substitute products or services. If a service provider suggests substituting one covered product or service for something that isn’t covered, decline the offer. Examples can include: a facial or spa services instead of a therapeutic massage; running shoes instead of orthotics; designer sunglasses instead of prescription eyewear; or teeth whitening instead of regular dental care.
Review Sun Life’s delisted provider list. Take the time to review Sun Life’s “delisted providers” list so that you don’t unknowingly use a delisted provider, which would result in your claim being declined.
To view the delisted providers, log on to www.mysunlife.ca or use the Sun Life mobile app. Select the message for delisted providers found on the left-hand side of the screen. You will need to ensure you have pop-up blockers turned off.
This list is updated periodically.
Sun Life’s Role in Fighting Fraud
Sun Life has a comprehensive fraud prevention, detection, and investigation program – with a team of professionals dedicated to these tasks. Sun Life sometimes finds it necessary to disallow claims from certain healthcare service providers, clinics, facilities, or medical suppliers to better protect your plan. When Sun Life delists a provider, this means that they will not process or pay for claims from that provider.
If you have any questions regarding a provider, please contact Sun Life’s Fraud Hotline, toll free at 1-888-882-2221 directly.