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What is insurance fraud?

Insurance fraud is intentionally providing false information or withholding information to ensure the payment of a claim. Insurance fraud can take many forms, from backdating a disability claim to submitting a fictitious or inflated medical or dental claim.

These and other forms of fraud increase the costs of benefits plans for your employer, and can put your benefits coverage at risk.

Anyone who has access to your insurance information can submit fraudulent claims—for example, you or your family members, doctors, dentists or other service providers.
 

What are the penalties?

Cases of fraud can be reported to your plan sponsor, which could lead to disciplinary action.

Like any crime, fraud can also be reported to the police. The penalties can range from repayment, to a criminal record, to jail time.
How does insurance fraud affect me?
 

How does insurance fraud affect me?

Insurance fraud is often referred to as a hidden crime, but the costs are quite visible. Both plan sponsors and plan members become the victims of insurance fraud through increasing premiums and the potential for reduced or lost plan benefits.

By being involved in the solution, you can help manage plan costs and protect your plan. Providing false claim documents or exaggerating services that were provided constitute fraud and can carry severe penalties.

What can I do?

You can help prevent fraud by being a responsible consumer. Be aware of who you give your benefits coverage information to and what you sign. You are responsible for the accuracy of any claims submitted on your behalf and any information you provide to support your claim.

Do not provide blank, signed claim forms to a service provider to submit the claim later. These can be used to submit fraudulent claims in your name.

Do not change a date on a claim or withhold information to ensure payment. If you need to know when you are covered for a particular benefit, contact us.

Be sure the claims you submit are for supplies and services that are medically necessary. Don't accept receipts for services or supplies you have not received.

Be wary of any advice you receive on how to ensure a claim is paid. You’re responsible for ensuring the claim information you submit is correct. Include any supporting documentation with your claim.

Be wary of aggressive marketing programs—for example, where a provider offers you a gift for becoming a client or for soliciting other employees to become clients, or offers to refer you to another provider for a prescription.

Watch for providers who charge 2 different fees—a higher fee for clients who have insurance and a lower fee for those who don’t.

Shop around. Costs can vary significantly among suppliers and providers. While most of the cost may be covered by your plan, higher prices can mean higher overall costs for your plan and may lead to reduced benefits.

Report suspicious situations

If you discover a suspicious situation, contact us.

Contact us