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Preventing fraud

Tuesday, January 13, 2015
Get More from Your Benefits, Lowering your out-of-pocket costs

Benefits Fraud = Real Crime with Real Consequences

Using your health or dental benefits dishonestly may seem harmless, but even a small infraction can have big - and potentially legal - consequences.

According to the Canadian Life and Health Insurance Association, in North America alone, it is estimated that hundreds of millions of healthcare dollars are lost to fraud. This impacts plan sustainability, pushes up monthly premiums and, more importantly, puts your health and wellbeing at risk.

What is Benefits Fraud?

Knowing how to spot benefits fraud is the first step in preventing it. Benefits fraud occurs when a person intentionally submits false or misleading information about the health or dental treatments they receive under an employer’s benefits plan. People engage in benefits fraud most often for financial gain, to assist a friend or family member or to obtain more treatments or services than their plan covers.

How to Spot Benefits Fraud

Engaging in benefits fraud can either be done intentionally, or you could be unexpectedly led into it by a service provider or others in your life. It’s important to understand how to spot benefits fraud so you can stop it before it happens. Here are a few examples of personal benefits fraud:

  • Letting a friend use your health or dental benefits because they have maxed out their own coverage.
  • Using your benefits to purchase non-prescription sunglasses and then claiming them as prescription.
  • Using a treatment or service for yourself, but then claiming it under a dependent’s benefit coverage.
  • Submitting a full claim for the same service to multiple insurers to double your reimbursement.
  • Buying trip cancellation insurance after you find out you require surgery and cannot go on a scheduled trip.

It is also important to ensure your service provider is following the rules of your benefits plan. Examples of provider-linked scenarios could include:

  • Being pressured by your health or dental care provider to get unnecessary products or procedures, or being encouraged to claim products or services that are not eligible under your coverage.
  • Being asked to sign a blank claim form (which could be completed later with fraudulent information).
  • Being encouraged to include incorrect or misleading information on a claim form.
  • Noticing your benefits plan has been charged by a service provider for products or services you did not receive.
  • Being offered cash or other incentives in exchange for your policy information.

If you experience a situation that seems suspicious, make sure to contact your insurer for assistance.

Consequences of Benefits Fraud

Many people think that if they are caught committing benefits fraud, they may only face higher premiums or having to refund the money. The truth is, the consequences could be far more serious, including: a loss of - or reduction in - your benefits, loss of your job or possible jail time and a criminal record.

What You Can Do

Know your Plan

It’s important to know the boundaries of your benefits plan and check your claims history regularly to ensure everything is being used appropriately. A few key tips:

  • Familiarize yourself with your benefits plan, including the limits of your coverage.
  • Keep your personal benefits plan access information in a safe place – do not share your Member card with anyone.
  • Ensure you understand the treatments, services and products being prescribed to you. Don’t be afraid to ask questions if you need more information.
  • Double check your explanation of benefits (EOB) forms and receipts provided by your insurer to ensure they accurately reflect the products and services you’ve claimed.
  • Let your insurer know if you notice anything suspicious.

Pacific Blue Cross is committed to protecting the integrity of benefit coverage and uses a combination of approaches to eliminate fraud. We use sophisticated fraud technology that utilizes data analytics on Member and Provider online claims to spot billing patterns and irregularities. We conduct audits of healthcare practitioners or Members if we notice unusual patterns of activity. We randomly audit member online claims and verify receipts to ensure that services or products are received. We also investigate tips sent in to the Pacific Blue Cross Whistleblower Hotline.

Whistleblower Hotline – Anonymous Fraud Reporting

The Whistleblower Hotline allows members, providers and employees to anonymously report fraud. Pacific Blue Cross investigates all incidents reported to the hotline, which is administered by an independent third party to ensure anonymity.

Pacific Blue Cross Members can submit tips to the Whistleblower Hotline either online at:, or by calling 1 800 661-9675.


Protecting your benefit plan

Pacific Blue Cross believes that the vast majority of plan members, health and dental providers, and groups are honest; however, there are a small percentage of people who will engage in fraud and abuse.

When fraud or abuse occurs, your benefit plan costs rise, which means higher plan premiums for consumers—for British Columbians like you. Individual plan members and group plan sponsors must ultimately pay every dollar of fraud or plan abuse.

We're committed to protecting your benefits from insurance fraud and abuse and as a plan member you can help by understanding insurance fraud and abuse and what to do about it.

Understanding insurance fraud and abuse and what to do about it

What is insurance fraud and abuse?

Insurance fraud is the intent to obtain reimbursement for claimable goods or services that were neither received nor provided. Examples of insurance fraud are:

  • Misrepresenting items supplied on receipts
  • Member returning items after reimbursement and not refunding PBC
  • Submitting claims for services not rendered
  • Altering receipts

Insurance abuse is any actions that use the benefit plan in a way that is contrary to the intended purpose of the benefit, which results in unnecessary cost to the plan. Examples of insurance abuse are:

  • Providing medically unnecessary treatments
  • Excessive use of benefits

Who commits insurance fraud?

Anyone that has access to your personal benefit information can commit insurance fraud or abuse.

How does insurance fraud affect you?

Insurance fraud and abuse may reduce the member's benefits and in some cases, high fraud risk benefits may be eliminated by the employer/plan sponsor altogether because of the financial risk.

What can you do to protect yourself from fraud?

Members can protect themselves and others from health insurance fraud and abuse by taking these steps:

  • Keep your PBC ID card and information in a safe place and report lost or stolen cards to your employer or PBC.
  • Monitor your claims submitted by the provider. You can review your claims information via your Member Profile, Pacific Blue Cross' online access to claims and benefit information for members. (
  • Never allow anyone else to use your PBC ID card.
  • Contact PBC if you suspect that someone is committing a fraud against your plan.

Providers can protect their business, as well as their patients/customers from health insurance fraud and abuse by taking these steps:

  • Verify that the patient you are about to provide services for is an actual PBC member by requesting picture identification
  • Ensure receipts are issued for exactly what was provided.
  • Validate patient chart information to remittance statements for accuracy.
  • Contact PBC if you feel that someone is falsely using a PBC Health and Dental card or is abusing the plan.

How do I report suspected fraud or abuse?

To report any fraud or abuse you can contact our confidential Whistleblower Hotline by:

Phone: 1.800 661-9675.

The Whistleblower Hotline is administered by CANPRO HRservice's Confidence Line™, an independent third party to ensure the strictest confidence and you are not required to provide your identity should you wish to remain anonymous. You will be issued a unique reference number, which can be used to provide additional information anonymously. The hotline is available 24/7.

Alternatively you can contact us by mail:

Pacific Blue Cross
Attn: Audit Services
PO Box 7000
Vancouver, BC V6B 4E1

Pacific Blue Cross' Audit Services will investigate all allegations of fraud and abuse. The information we receive will be kept confidential to the extent possible.

Are calls to the fraud hotline recorded?

Yes, the calls are recorded. CANPRO HRservice's advises every caller that the call is recorded for accuracy purposes and is strictly intended for the use of ConfidenceLine only.

What happens to the person being reported?

If the allegation is substantiated, we will take the appropriate action. This may include but not limited to recovery of funds, termination from the plan or notifying law enforcement.

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