Benefits fraud impacts everyone in the benefits plan. Over time, it can lead to increased costs and reduced coverage. Learning what you can do to help prevent benefits fraud and abuse of your plan is an important step in ensuring sustainable benefits coverage for you and your family.
Your group benefits plan is provided to you by the ETFO Employee Life and Health Trust (ELHT), which was established for the sole purpose of providing benefits to you and your family. The ELHT is required to ensure that the benefits plan is managed on a sustainable and efficient basis. The ELHT is funded by monies negotiated by your union, and those funds are provided by the Ministry of Education to the ELHT via your school board.
The amount of benefits coverage your plan can provide is directly related to the costs of claims paid by the benefits ELHT. Benefits fraud and abuse can have a big impact on this bottom line, as it has a direct impact on the ability for your plan to provide optimum coverage amounts, lower premium costs and allow for overall plan sustainability. While some consider benefits fraud a victimless crime, in reality it impacts every member of the group benefits plan.
Benefits Fraud vs. Abuse
Recognizing benefits fraud and benefits abuse is one of the most important steps you can take in helping to prevent it.
Fraud is the intentional submission of false or misleading information for the purpose of financial gain. Fraud is a crime, and those who are convicted face serious consequences, including potential job loss, criminal conviction, jail time and fines.
Some common examples of provider/plan member fraud include:
Abuse is taking advantage of the contract’s provisions and/or the health professional’s guidelines for personal gain. This includes overuse of services, excessive billing and providing treatment when there is no proven medical need. While misuse is not against the law, it is unethical and can have a big impact on a group benefits plan.
Some common examples of provider/plan member abuse include:
How you can help?
Fraud and abuse can be committed by service providers, plan members, or both working together. Sometimes benefits fraud or abuse can happen without the plan members consent or knowledge. With this in mind, there are many things that you can do as a plan member to help protect your plan, and yourself, from benefits fraud and abuse.
Every dollar paid out as a result of a fraudulent claim is one more dollar that is not available for legitimate health-care needs. Any claim suspected to be fraudulent is thoroughly investigated by Manulife, and claims proven to be fraudulent are reported to the ELHT for review and action in accordance to the our anti-fraud policy.
Benefits fraud impact everyone (Manulife, INS5375 02/2016)
Recognizing benefits fraud (Manulife, CS5147E 03/17)