Insurance Fraud and Abuse
Insurance fraud and abuse are not victimless offences. They have many consequences that impact all of us and can lead to higher insurance rates, benefits not being offered under health plans and employers choosing to reduce benefits to keep escalating costs down.
What to do if you know someone potentially engaging in insurance fraud or abuse
If you know or suspect someone who is potentially engaging in insurance fraud or abuse, report it anonymously to Manitoba Blue Cross
- within Winnipeg, call 204.789.8805
- within Canada, call toll-free 1.877.998.TIPS (8477)
- online, use the form below
What is Insurance Fraud?
Insurance fraud is the intent to obtain reimbursement for goods or services that were neither received nor provided.
Examples of insurance fraud:
- misrepresenting items supplied on receipts
- returning items after reimbursement and not refunding Manitoba Blue Cross
- submitting claims for services not rendered
- altering receipts - including patient name, billed amount, service date, etc.
What is Insurance Abuse?
Insurance abuse is any action that utilizes the 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:
- receiving services that are not part of a therapeutic treatment for illness or injury
- excessive use of benefits
How can you prevent insurance fraud and abuse?
- Never sign blank claim forms for providers. By signing forms, you are confirming your authorization and consent as well as verifying the accuracy of the information in the claim being submitted on your behalf.
- Verify that your provider is approved by and registered with Manitoba Blue Cross prior to obtaining services.
- Ensure that the benefits you are claiming are the goods and services that you received.
- Treat your Manitoba Blue Cross card like a social insurance number; do not let anyone use your number.
- Ensure that all receipts submitted reflect the accurate dates and payments and that services have been provided in full before submitting a claim.
- Report any incidences of providers offering to alter claim information to meet your claiming requirements.
- Report any incidences of providers recommending services to maximize your benefit payments.
- Notify Manitoba Blue Cross if you return an item that had been previously processed under your plan.
- Keep records of appointments and treatment dates and receipts for co-payments.
- Review your Explanation of Benefits for claims where the provider submits directly to Manitoba Blue Cross on your behalf.
How do we at Manitoba Blue Cross prevent insurance fraud and abuse?
Manitoba Blue Cross takes a number of approaches to fraud and abuse prevention.
We have a profiling system designed to:
- monitor claiming practices
- identify abnormal billing patterns
- identify over-utilization of services
- identify excessive fees
- recognize potential abuse
Furthermore, our staff is educated on a variety of fraud detection techniques and processes. Specifically, our Claims and Information Services staff is trained to identify red flags such as altered claim forms and/or receipts, unusually high charges or claim frequencies. We have a Benefit Services Investigative Unit that conducts audits based on confidential tips, random selection and profiling results.
All tips and red flags are taken seriously and investigated.
Consequences of insurance fraud or abuse
Depending on our findings, we may:
- educate a member on appropriate claiming and billing procedures
- cancel a member's coverage
- request restitution directly from members and send unpaid accounts to collection agencies
- initiate civil proceedings
- forward our findings to local authorities for criminal investigation
Did you know?
- One unit of scaling or polishing (as part of a dental cleaning) means 15 minutes of time. Make a note of how long it takes to get your teeth cleaned (excluding the time it takes for your examination, X-rays and fluoride). Discuss any discrepancies about the number of units billed with your dental office and contact Manitoba Blue Cross if you have any unresolved issues.
- Physiotherapy, occupational therapy and athletic therapy are different types of treatments and are treated as separate benefits even though some similar techniques can be used to treat similar ailments. Make sure you know what credentials your therapist has before receiving treatment and verify their eligibility with Manitoba Blue Cross.
- Prior approvals are recommended for any claims over $500 but may be submitted for any claim amount if you are unsure about your coverage.
- Spa treatments such as facials are not eligible expenses. Even if they are performed by an eligible provider (i.e., a massage therapist), they are not for the treatment of illness or injury.
- Manitoba Health partially subsidizes your first 12 chiropractic adjustments in every calendar year by $11.00 per visit. Verify with your chiropractor's office whether they are collecting this subsidy on your behalf or whether you should claim this amount directly from Manitoba Health on your own. If your chiropractor is collecting this subsidy on your behalf, the fees charged to you should be reduced accordingly. Manitoba Blue Cross plans are second payer to government plans.
- You must request a semi-private room during a hospital stay for the charges to be paid by your plan. If you are placed in a private or semi-private room due to lack of space in ward rooms or due to your medical condition, your Blue Cross plan should not be charged.
- Blue Cross is second payer to Manitoba Public Insurance (MPI) and Workers Compensation (WCB). If your injury or illness was a result of a motor vehicle accident or an incident at work, all related medical expenses that are eligible under MPI or WCB are not covered under your Manitoba Blue Cross plan.