Education key to tackling fraud, says CLHIA

by James Burton13 Mar 2019

The Canadian Life and Health Insurance Association is taking the fight to benefit fraudsters as it aims to raise awareness and education through its Fraud=Fraud campaign.

As part of Fraud Prevention Month, the organisation wants to help Canadians learn to recognize how and when it happens, and how to avoid getting involved in fraudulent activities. Worryingly, according to research by Environics Research, 75% of Canadians incorrectly believe that the only punishment for benefits fraud is having to pay higher premiums or be forced to reimburse claim payments.

The reality is, of course, that it’s a crime and could cost someone their job or even result in jail time. Through its site, the CLHIA is providing resources to identify and report benefit fraud.

Shannon DeLenardo, director of anti-fraud and electronic claims at CLHIA, said examples of fraud includes people sending in bills or claims for services that were not provided, while there is often collusion between plan members and providers who work together to cheat the system.

She told LHP: “The plan member goes to the provider and they say instead of getting prescription glasses or whatever the provider is offering in terms of product or service, we’ll send in the claims, you’ll get reimbursed and you can come back and select from some designer purses or shoes and use your money that way.

“That’s the hardest one to prove, the collusion, because they are working together and it is in their best interests to protect one another.”

One way the CHLIA hopes to address the problem is by pooling data so when member companies see a suspicious transaction, they can flag it. A pilot project is under way and DeLenardo believes it will help the industry identify the collusion.

She said: “Fraudsters are pretty smart and have sophisticated schemes. So they know that a particular insurer has an analytic system in place and they’ll raise a flag at six hours of service being provided in a day. Whereas, if we pool the data across the industry, they may be putting those six hours to four different insurers and we won’t know that unless it’s pooled together.”

Education is key and some of the fraud is down to naivety and lack of understanding, she said. Passing on your unused massage allocation to family members is fraud, for example.

She added: “Our website goes a long way to educating consumers. 75% of Canadians don’t understand how severe the consequences are. They see it as a victimless crime but it isn’t – it’s a real crime with real consequences.”