本文发表在 rolia.net 枫下论坛For employees in Canada – You have a role in fighting fraud and protecting your benefits plan Mar. 17, 2008
Did you know that as a group benefits plan member you have an important role to play in ensuring all costs incurred under your plan are accurate and legitimate?
March is Fraud Prevention Month and the Investigative Services team at Manulife Group Benefits wants employees to be aware of what’s being charged to their benefits plan and report anything that looks unusual by calling the confidential tip line at 1-877-481-9171. How You Can Help Prevent Fraud
Never sign blank claim forms
Report any provider that asks you to pre-sign a blank claim form
Do not submit a claim prior to receiving the treatment, service or product
Make sure you understand the treatments you are receiving as well as how your benefits plan works
Complete claim audit questionnaires
Notify and reimburse Manulife if items that you purchased through the plan are returned for a refund
Review your Explanation of Benefits OR online claims history and report anything you don’t recognize
If you suspect fraud or the possible abuse of your benefits plan, report your concerns to gb.investigative.services@manulife.com or anonymously by calling 1-877-481-9171. You can also visit www.manulife.ca/stopbenefitsfraud to learn more about how your benefits plan works and your role in fraud prevention.
“The vast majority of health and dental service providers are ethical,” says Jeff Alcock, Manager of Investigative Services for Manulife Group Benefits. “But, for a very small group, benefits plans can be tempting to exploit for personal gain.”
It’s that small group that is the focus of his team’s efforts. “Our plan sponsors — including Manulife in its role as an employer — depend on us to protect their investment in health care,” adds Alcock. “If inappropriate claims get paid, they can lead to negative impacts on the premiums paid by both employers and the employees themselves.”
Comprised of fraud examiners, data analysts, health/dental consultants and former law enforcement professionals, the Investigative Services team uses both proactive and reactive tactics to uncover benefits plan fraud and abuse. This ranges from investigating anonymous tips from concerned plan members to identifying unusual patterns of claim and payment activity through data analysis and profiling.
In addition, Manulife's claims and call centre employees are trained to spot things such as altered receipts, suspiciously high charges and unusual claims frequency.
As a result, Manulife has been able to identify inappropriate claims such as:
Claims by patients who tamper with documents to obtain reimbursements for payments they haven’t made.
Claims by health care providers who submit false information to obtain more money than they are entitled.
In the case of the latter, one major incident involved a dental provider who submitted claims for services that were never performed including fillings, root canals and extractions. The scheme was recognized when an alert plan member reviewed her Explanation of Benefits and reported the discrepancy to Group Benefits Investigative Services.
The dentist ended up pleading guilty to fraud over $5,000. He received a suspended sentence, 18 months probation, 100 hours of community service and was ordered to undergo counseling. He also had to make a $5,000 donation to Sick Kids Hospital and pay $8043.66 in restitution to Manulife. Eventually, the dentist voluntarily withdrew from practice.
“We have an obligation to maintain the trust and confidence of our customers,” says Joanne Keigan, VP of Group Operations. “They want to know that their benefits plan is protected. And, if a fraud or abuse does occur, they want to be assured that we can detect it and will take the steps necessary to address it. I am very proud of our track record over the years and the reputation we have earned because of it.”
When Manulife has reason to suspect a case of fraud or abuse, an investigation is conducted in an attempt to recover any money that has been obtained improperly. In cases where plan member fraud is identified, the employer will be contacted and provided details of the findings. And when the likelihood for a successful prosecution exists, a criminal complaint is submitted to the appropriate law enforcement agency.
Since January 2004, more than $28 million has been saved by the Fraud Prevention Program controls initiated by Group Benefits. In 2007 alone, there were 1,632 tips sent to Investigative Services resulting in 26 referrals to regulatory bodies and six referrals to law enforcement services.
“Having employees play a role in fighting the fraud and abuse of their benefits plan reinforces our company’s PRIDE values,” says Patty Johns, Vice President of Human Resources Operations. “If an employee suspects something is amiss, we want to ensure that they know exactly what to do.”
Did you know?
Fraud is the intentional submission of false or misleading information for the purpose of financial gain.
Abuse occurs when a health care provider or consumer exploits the plan provisions or the health profession's guidelines. This includes over billing for services, providing treatment when it is not necessary, overusing services, or returning items after the plan has reimbursed the costs.更多精彩文章及讨论，请光临枫下论坛 rolia.net
Did you know that as a group benefits plan member you have an important role to play in ensuring all costs incurred under your plan are accurate and legitimate?
March is Fraud Prevention Month and the Investigative Services team at Manulife Group Benefits wants employees to be aware of what’s being charged to their benefits plan and report anything that looks unusual by calling the confidential tip line at 1-877-481-9171. How You Can Help Prevent Fraud
Never sign blank claim forms
Report any provider that asks you to pre-sign a blank claim form
Do not submit a claim prior to receiving the treatment, service or product
Make sure you understand the treatments you are receiving as well as how your benefits plan works
Complete claim audit questionnaires
Notify and reimburse Manulife if items that you purchased through the plan are returned for a refund
Review your Explanation of Benefits OR online claims history and report anything you don’t recognize
If you suspect fraud or the possible abuse of your benefits plan, report your concerns to gb.investigative.services@manulife.com or anonymously by calling 1-877-481-9171. You can also visit www.manulife.ca/stopbenefitsfraud to learn more about how your benefits plan works and your role in fraud prevention.
“The vast majority of health and dental service providers are ethical,” says Jeff Alcock, Manager of Investigative Services for Manulife Group Benefits. “But, for a very small group, benefits plans can be tempting to exploit for personal gain.”
It’s that small group that is the focus of his team’s efforts. “Our plan sponsors — including Manulife in its role as an employer — depend on us to protect their investment in health care,” adds Alcock. “If inappropriate claims get paid, they can lead to negative impacts on the premiums paid by both employers and the employees themselves.”
Comprised of fraud examiners, data analysts, health/dental consultants and former law enforcement professionals, the Investigative Services team uses both proactive and reactive tactics to uncover benefits plan fraud and abuse. This ranges from investigating anonymous tips from concerned plan members to identifying unusual patterns of claim and payment activity through data analysis and profiling.
In addition, Manulife's claims and call centre employees are trained to spot things such as altered receipts, suspiciously high charges and unusual claims frequency.
As a result, Manulife has been able to identify inappropriate claims such as:
Claims by patients who tamper with documents to obtain reimbursements for payments they haven’t made.
Claims by health care providers who submit false information to obtain more money than they are entitled.
In the case of the latter, one major incident involved a dental provider who submitted claims for services that were never performed including fillings, root canals and extractions. The scheme was recognized when an alert plan member reviewed her Explanation of Benefits and reported the discrepancy to Group Benefits Investigative Services.
The dentist ended up pleading guilty to fraud over $5,000. He received a suspended sentence, 18 months probation, 100 hours of community service and was ordered to undergo counseling. He also had to make a $5,000 donation to Sick Kids Hospital and pay $8043.66 in restitution to Manulife. Eventually, the dentist voluntarily withdrew from practice.
“We have an obligation to maintain the trust and confidence of our customers,” says Joanne Keigan, VP of Group Operations. “They want to know that their benefits plan is protected. And, if a fraud or abuse does occur, they want to be assured that we can detect it and will take the steps necessary to address it. I am very proud of our track record over the years and the reputation we have earned because of it.”
When Manulife has reason to suspect a case of fraud or abuse, an investigation is conducted in an attempt to recover any money that has been obtained improperly. In cases where plan member fraud is identified, the employer will be contacted and provided details of the findings. And when the likelihood for a successful prosecution exists, a criminal complaint is submitted to the appropriate law enforcement agency.
Since January 2004, more than $28 million has been saved by the Fraud Prevention Program controls initiated by Group Benefits. In 2007 alone, there were 1,632 tips sent to Investigative Services resulting in 26 referrals to regulatory bodies and six referrals to law enforcement services.
“Having employees play a role in fighting the fraud and abuse of their benefits plan reinforces our company’s PRIDE values,” says Patty Johns, Vice President of Human Resources Operations. “If an employee suspects something is amiss, we want to ensure that they know exactly what to do.”
Did you know?
Fraud is the intentional submission of false or misleading information for the purpose of financial gain.
Abuse occurs when a health care provider or consumer exploits the plan provisions or the health profession's guidelines. This includes over billing for services, providing treatment when it is not necessary, overusing services, or returning items after the plan has reimbursed the costs.更多精彩文章及讨论，请光临枫下论坛 rolia.net