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Silverberg Group - Bringing Your Employee Benefits into Focus

March is Fraud Prevention Month

jpeg-4In July 2015, national headlines revealed a massive benefits fraud scheme out of Ontario. The parties involved included Toronto Transit Commission (TTC) employees and local health care providers, who had colluded to defraud TTC’s group benefits plan for over four million dollars through false claims that were made between employees and medical supply stores. Over 600 people were under investigation and 73 employees were recently dismissed in connection with the scheme. While the TTC is a huge organization with over 13,000 employees, benefits fraud has been known to affect much smaller companies as well. These smaller organizations are often hit harder than the larger ones, usually because they are on a tighter budget and may have less money to allocate to unforeseen benefit expenses. Sun Life Financial estimates that a business with 100 employees spends roughly $300,000 to $400,000 on a group benefits plan and that up to 10% of claims could be fraudulent. This suggests that an organization with 100 employees could be paying premiums or claims for up to $40,000 per year due to fraudulent benefits activity.

A popular trend in fraud in the past few years, has been seen in the foot orthotics industry. In this scheme, disingenuous health care providers provide fake orthotic footwear or inserts to employees and charge industry standard rates for medical grade inserts/footwear. The money obtained through the benefits plan claim is then split between the provider and the employee. While collusion is the most common form of fraudulent claims, sometimes claims fraud can happen by accident; in this case it is important to ensure that your employees are educated about their plan and aware of what kind of behavior could make them susceptible to fraud.

Some key tips to remember include:

  1. Protecting your personal information which includes your benefits plan access information.
  1. Not letting someone else borrow your card to obtain services or products.
  1. Ensuring your receipts are correct and reflect the service or treatment you received.
  1. Alerting your insurer of any providers who routinely waive your co-payment or deductible.
  1. Remembering to keep your receipts as you may be asked to submit them in support of your claim.
  1. Understanding the limits that apply to your plan.
  1. Not being afraid to ask questions about the treatment or services being prescribed.
  1. Not signing blank claim forms.

In closing, it is important to be watchful of any unusual trends within your organization and report anything that seems out of the ordinary to your carrier and/or group benefits advisor. We pride ourselves at Silverberg Group on looking out for our clients and these trends – if you have any questions please don’t hesitate to contact us today.


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