Your group benefits plan is provided to you by the ETFO Employee Life and Health Trust (ELHT) and was established to help cover or supplement the cost of delivering health and dental benefits to you and your family.

The ETFO ELHT is responsible for ensuring that your benefits plan is managed sustainably and efficiently. The level of coverage your ETFO ELHT plan provides is directly related to the funding received by the ETFO ELHT.

Benefits fraud and abuse can put the ETFO ELHT plan at risk and has negative consequences for the sustainability of your benefits plan.

Benefits fraud and abuse can lead to higher costs, reduced coverage, or both. While some consider benefits fraud a victimless crime, it impacts every member of the ETFO ELHT benefits plan. It also directly impacts the ability of your ETFO ELHT to provide optimum coverage amounts and maintain overall plan sustainability.

Benefits fraud vs. abuse

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:

• Falsifying procedures to receive payment for health and/or dental expenses that are not eligible.
• Providing invoices that have been changed.
• Billing for health and/or dental services that haven’t been provided.
• Returning items after reimbursement.
• Submitting claims for forged or stolen prescriptions.
• Submitting claims from healthcare or dental clinics that don’t exist.

Abuse is when a health/dental provider and/or ETFO ELHT plan member take advantage of your ETFO ELHT benefits plan provisions for personal gain. This includes overuse of services, excessive billing, and accessing or providing treatment when there is no proven medical need. These types of benefits abuses have a negative impact on your ETFO ELHT benefits plan. Some common examples of provider/plan member abuse include:

• Providing/accessing medically unnecessary treatments and/or treatments for longer than necessary.
• Offering/accepting incentives such as free gifts (e.g. “free” shoes) to encourage maximum use of benefits.
• Referring patients unnecessarily to other providers in a practice or clinic.
• Encouraging all family members to access treatment not medically required.
• Using benefits up to the specific maximums where applicable, even if the products and services are not medically necessary or the products will not be utilized.
• Visiting multiple doctors and/or pharmacies to get narcotics.

You can help protect your ETFO ELHT plan. Here’s how. 

Fraud and abuse can be committed by service providers, plan members, or both parties. Sometimes benefits fraud and/or abuse can happen without the plan member’s consent or knowledge. As an ETFO ELHT plan member you can help to protect your plan, and yourself, from benefits fraud and abuse. 

Do:

• • Use your ETFO ELHT plan for its intended purpose – coverage for eligible expenses incurred for the medically-necessary treatment of illness or injury.
  • Make sure your health/dental provider is licensed with the appropriate regulatory board and has not been delisted by the claims payor, Manulife. To find out which service providers have been delisted and avoid delays in processing your claims, check out how can I view the list of delisted providers.
  • Make sure that you are not being charged for extra services/equipment, that you understand the services you are receiving, and your receipts accurately reflect those services.
  • Notify and reimburse the claims payor, Manulife, if you return previously claimed items for a refund.
• Report odd or suspicious behavior or practices to OTIP Benefits Services at 1-866-783-6847. We also encourage you to review your claim statement or Explanation of Benefits (EOB) for accuracy and report any concerns or billing discrepancies. 

Do not:

• Be enticed to use your plan through the offer of cash rebates, “free” shoes, or other products.
• Sign blank health and/or dental claim forms. Be sure to report dental and health-service providers who ask you to sign them.
• Submit a claim prior to receiving the dental or medical treatment, product, or service.
• Accept receipts for services or supplies you have not received.
• Share your ETFO ELHT plan and ID numbers with anyone other than your eligible dependants or service providers you have authorized to submit electronic claims on your behalf.
• Share or give anyone (including your dependants) your password to your OTIP member site, as you are responsible for your plan activity. 

Every dollar paid out due to a fraudulent claim is one more dollar that is not available for legitimate dental or healthcare needs. Any claim suspected to be fraudulent is thoroughly investigated by Manulife, and claims proven to be fraudulent are reported to the ETFO ELHT for review and action in accordance with the ETFO ELHT’s anti-fraud policy.  To review your ETFO ELHT anti-fraud policy, click here.  

If you suspect that someone you know or a service provider may be committing fraud, you can report it to your ETFO ELHT, OTIP, or Manulife. It is our shared responsibility to protect the ETFO ELHT plan and report fraud when we see it.
 
Questions? Check your benefits booklet for benefit plan terms and coverage details. You can also contact OTIP Benefits Services at 1-866-783-6847.

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