Protect your benefits

February 28, 2024

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Your ETFO ELHT benefits plan helps to cover or supplement the cost of providing health and dental care benefits to you and your eligible family members. But benefits fraud can put your benefits at risk. For example, billing or claiming for services that never occurred and falsifying frequency or description of services rendered has significant consequences for you, your service provider, and your benefits plan. 

 

Why does this matter to you?

Benefits fraud makes the cost of providing benefits more expensive and may lead to reduced coverage and/or reimbursement levels

When plan members commit benefits fraud, it’s not stealing from the insurance company; it’s stealing from your plan and colleagues (i.e. other plan members). Every dollar paid out for a fraudulent claim is a dollar that is not available for legitimate health and dental care needs and may result in reductions in plan coverage as funding is defined. Plan members who commit benefits fraud will face serious consequences including:

  • Permanent suspension of online claims submission privileges.
  • Delay in new eligible claims (until Manulife is reimbursed for the fraudulent claim(s), new eligible claims will not be reimbursed to the plan member or providers, but will instead be used to pay back the fraudulent claims to the plan).
  • Reporting of the fraud to law enforcement.

 

The claims payer of the ETFO ELHT benefits plans (Manulife) will routinely and randomly audit benefit claims, and you may be asked to provide additional information about a claim. Be sure to keep your claim receipts for up to 12 months from the date you submit a claim

Claims from providers that are deemed fraudulent are identified as ‘delisted’ providers by Manulife and will not be approved or eligible for reimbursement. To avoid paying out-of-pocket for claims, check the list of delisted providers before you book your next appointment.

You play a key role in safeguarding your plan to keep your benefits affordable, accessible, and sustainable for when you, your family and your colleagues need it. 

 

How can you protect yourself and the plan?

Understanding your benefits and how to use them appropriately can help you safeguard yourself and the plan against potential fraud and abuse. Here’s how:

  • Familiarize yourself with your benefits plan and the limits of your coverage.
  • Keep your benefits plan information, card, and OTIP plan member site password in a safe place and do not share it with anyone. 
  • Make sure your practitioner is licensed with the appropriate regulatory board and is covered under your plan.
  • Ask questions of your service providers so you understand the treatments, services, and products being prescribed to you.
  • Check that the explanation of benefits (EOB) contains accurate information about the services or products you received when your provider submits your claim.
  • Notify and reimburse Manulife if you return previously claimed items for a refund.

 

To help you learn how to spot benefits fraud and what steps you can take if you suspect fraudulent activities, read the frequently asked questions below. 

 

What does benefits fraud look like?
Benefits fraud involves intentionally submitting false or misleading information to an insurance provider for financial gain [1]. It can be committed by service providers and plan members, or both working together. Sometimes, benefits fraud occurs without your consent or knowledge. Some examples include:

  • Letting someone not covered by your plan use your benefits.
  • Claiming/billing for health or dental services that were not received/provided.
  • Submitting the same claim to multiple insurers.
  • Using your benefits to buy non-eligible items (e.g. non-prescription sunglasses submitted as prescription eyeglasses).
  • Submitting claims for services provided only by the assistant (i.e. not by the licensed and eligible provider).
  • Falsifying procedures to receive payment for non-eligible expenses.
  • Returning items after reimbursement and not repaying the claims payment received.
How does benefits abuse differ from benefits fraud?
Benefits abuse means taking advantage of the contract’s provisions and/or health professional guidelines for personal gain. While misuse is not against the law, it is unethical and has a negative financial impact on your plan. Some examples include:

  • Using benefits up to the specific maximums when they are not medically necessary.
  • Providers offering medically unnecessary treatments.
  • Providers offering incentives such as free gifts to encourage maximum use of benefits.

Every dollar paid out for an incident of claims abuse is a dollar that is not available for legitimate medically necessary health and dental care needs and may result in reductions in plan coverage as funding is defined. Plan members will be required to repay reimbursements for medically unnecessary services/treatment, supplies, and equipment.

What should I do if I suspect benefits fraud?
Benefits fraud affects everyone, and it’s our shared responsibility to report it when we see it. If you suspect that someone you know or a service provider may be committing fraud, you can report it to ETFO ELHT, OTIP, Manulife, or anonymously to the CLHIA.

 

Safeguarding your benefits by keeping an eye out for fraud will help to keep your benefits affordable, accessible and sustainable for many years to come.

Claims proven to be fraudulent are reported to the ETFO ELHT Board of Trustees for review and action in accordance with plan policy. To learn more about benefits fraud, including what steps might be taken if fraud is suspected, visit the ETFO ELHT Anti-Fraud Policy

 

[1] https://fraudisfraud.ca. Canadian Life and Health Insurance Association Inc.

Questions?


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