Help Recognize and Prevent Benefits Fraud

Fraudulent benefit claims cost Canadians between one and six billion dollars every year, but did you know that benefits fraud can be committed by health or dental service providers, plan members or both?¹

The life and health insurance industry has seen increasing evidence of service providers encouraging individuals to submit fraudulent claims, which is why they launched the Fraud=Fraud campaign in October 2018. The campaign aims to raise awareness of health and dental benefits fraud by helping Canadians to:

• Recognize benefits fraud
• Understand how to avoid becoming involved in fraudulent activities
• Realize that benefits fraud is a crime and therefore has real consequences

What are some examples of benefits fraud?

Learning how to recognize benefits fraud is a first step towards preventing it. Here are some examples of benefits fraud:

• Billing for services that never occurred
• Health or dental service providers falsifying medical conditions to provide an unnecessary treatment or service
• Health or dental service providers and plan members conspiring to increase the amount of a claim to ensure full coverage, so the plan member doesn’t have to pay the deductible
• Claiming services different from those provided
• Transferring unused benefits to others, such as using dependent’s unused benefits to cover another’s health or dental expenses

How could this affect your benefits?

• Coverage levels could be at risk because UBC is required to pay more for benefits coverage.
• Sun Life may find it necessary to disallow certain medical and dental service providers from claims processing and reimbursement in an effort to better protect the plan. These providers are placed on a Sun Life “delisted providers” list.

Take the time to review Sun Life’s list, so that you don’t unknowingly use a delisted provider, which would result in your claim being declined. This list is updated periodically.

To view the Sun Life delisted providers list:

1. Log in to www.mysunlife.ca or use the Sun Life mobile app.
2. Select “Coverage Information” and then the message for delisted providers found on the right-hand side of the screen. You will need to ensure you have pop-up blockers turned off.

How can I help prevent benefits fraud?

• Know your plan. Familiarize yourself with your benefits plan and any applicable limits/maximums.
• Understand the treatments, services and products provided to you. Don’t be afraid to ask questions.
• Keep your benefits information confidential. Keep your drug card, certificate/member ID and plan/policy number in a safe place and don’t give it to anyone.
• Check your explanation of benefits and receipts. Make sure your receipts are correct and reflect the services you actually received. If your service provider submits claims electronically for you, cross-check your receipt/invoice with the explanation of benefits (EOB) provided by Sun Life to confirm both reflect the services you received.
• Never sign claims forms in advance. Don’t sign blank claims forms in advance of services being performed.
• Report suspicious activity. If you notice anything suspicious, contact Sun Life’s Fraud Hotline at 1-888-882-2221 or email clues@sunlife.com.

For more information:

Visit the following websites to learn more about the Fraud=Fraud campaign, as well as the insurance industry and Sun Life’s efforts to prevent benefits fraud:

• Fraud=Fraud Campaign
• CLHIA – Healthcare Anti-Fraud
• Sun Life Financial – Fraud Management

References:

¹ Canadian Life and Health Insurance Association – Healthcare Anti-Fraud