Pacific Blue Cross joins national benefits program to fight benefits fraud

Wednesday, Sep 13, 2023

The national benefits industry initiative uses artificial intelligence (AI) to enhance the detection and investigation of benefits fraud.

Pacific Blue Cross is now a participating insurer with Canadian Life and Health Insurance Association (CLHIA)’s new initiative, which uses advanced AI to study pooled anonymized claim data from all participating insurers.

Launched in February 2022 by CLHIA and their technology partner, the AI tool detects suspected claims fraud and abuse by identifying patterns across millions of records. The program enhances the effectiveness of benefits fraud investigations across the industry.  It also creates an opportunity to undertake joint investigations, increasing the success in reducing fraud.

As an organization, we are committed to protecting the integrity of benefit coverage and use a combination of approaches to eliminate claims fraud and abuse. We use sophisticated fraud technology that utilizes data analytics on Member and Provider claims to spot billing patterns and irregularities. We also conduct audits of health and dental practitioners and Members if we notice unusual patterns of activity, and we audit member online claims and verify receipts to ensure that services or products are received. Pacific Blue Cross has a dedicated Whistleblower Hotline that allows anyone to anonymously report fraud, as well as an email address to report fraud directly to our Pacific Blue Cross Claims Fraud and Abuse team.

It is estimated that employers and insurers across Canada lose hundreds of millions of health care dollars to fraud each year. This impacts plan sustainability, pushes up monthly premiums and, more importantly, puts your health and wellbeing at risk.

For more information on benefits fraud and protecting your benefits plan, please visit Preventing Fraud.

Report Fraud

Report suspected Fraud to Pacific Blue Cross Investigations directly or anonymously via our third-party Whistleblower Hotline: