Protecting Your Employee Benefits Plan From Abuse And Misuse

You wouldn’t pay a credit card bill for something you did not buy, would you? We think the same logic applies to your employee benefits plans—no one should pay for bogus claims.

March is Fraud Prevention Month. It’s a great time to remind everyone about the importance of protecting their benefits from abuse.

Like everything of value, your employee benefits plan deserves to be well-protected. Benefits fraud hurts everyone and can result in
higher premiums.

Generally, most people submit their claims in good faith. Unfortunately, some people see their benefits plans as a source of extra income to be tapped. Our specialized claims
investigation unit has the tools and training to watch for:

• Healthcare providers who submit false claims. Some submit treatments they never performed; others inflate the cost and complexity of their work—or prolong the duration of treatments unnecessarily. Some bill a service as something else, as a way to get around eligibility rules and maximums.
• Employees who misuse their benefits. Some fabricate receipts for services they never had while others adjust the amount to claim more money. Still others avail themselves of services they don’t need, out of a misplaced sense of entitlement. When it comes to disability claims, some people double dip: earning unclaimed income under the table while collecting costly benefits.
• Plan sponsors who collude with providers or employees to make false claims. It’s rare, but it happens.

 Tips for customers

Left unchecked, fraud hurts everyone and can ultimately make a plan unsustainable. That’s not good for anyone. You play an important role in preventing benefits plan fraud and abuse. Here’s what you can do.

Treat benefits fraud and claim abuse as a serious matter

• It’s estimated that $12 billion is lost to healthcare fraud each year.
• Benefits fraud is a serious offence – offenders are stealing from your plan.

Increase awareness – communicate with your employees

• See that everyone receives a copy of their benefit booklet so they are familiar with what their plan covers.
• Educate employees about their role in preventing misuse, abuse, and fraud. Explain how it can drive up costs and could force you to reduce coverage.
• Encourage your employees to be a partner in maintaining the health of their benefits plan through consistent communication and tips.

Collaborate with us on claim audits

Claim audits help prevent and detect benefits fraud and claim abuse. Talk to your Advisor about benefits plan design options that can help prevent inappropriate claims. Examples of things to consider include:

• Dollar maximums on services that are commonly abused, such as medical supplies, orthotics, and massage therapy.
• Combined maximums to decrease overall risk.
• Co-pays to encourage employees to use their benefits wisely.
• A Healthcare Spending Account (HCSA) to limit expenses but still offer flexibility

Tips for employees

You can help protect your employee benefits plan from fraud and abuse. Here’s how:

• Review your employee benefit booklet to understand your coverage.
• Keep your benefits information confidential.
• Ensure your health care provider has legitimate credentials.
• Submit claims online whenever possible – there are lots of checks and balances in place to protect you and your benefits.
• Check your receipts and explanation of benefits. Report discrepancies between services/products received and what was billed.
• Never pre-sign blank claim forms.
• Understand the need for claim audits and actively participate in them.
• Report suspicious activity to your employer or to your benefits carrier immediately.

Source:The Empire Life Insurance Company