Top 10 Benefits Fraud Prevention Tips 1. Employers should instruct - - PowerPoint PPT Presentation

Premier Health & Benefits

Tips on How to Recognize and Stop Benefits Fraud

• 1. Employers should instruct their members to watch for

providers who try to use their plan member information (i.e., usernames, passwords and other personal information) to charge for products and services they never received.

• 2. The explanation of benefits received by the member contains

products or services they received. Employers should educate members to always review their explanation of benefits and report any discrepancies to the plan administrator.

Top 10 Benefits Fraud Prevention Tips

Top 10 Benefits Fraud Prevention Tips

• 3. Providers may request (supposedly for the member’s

convenience) that the member sign a blank claim form. By having a signed healthcare or dental claim form, it is much easier to commit fraud in your member’s name.

• 4. Providers may attempt to entice members to claim for

products and services not eligible as a benefit under your plan by using benefit codes that are eligible for reimbursement (e.g., a spa day treatment submitted as massage therapy, designer sunglasses submitted as prescription glasses).

Top 10 Benefits Fraud Prevention Tips

• 5. Members can be offered cash or other incentives in

exchange for their policy and certificate numbers. If this takes place, members should report the details to the administrator

• f anyone asking for this type of information.
• 6. Members should be on guard if their health care provider

appears more concerned about obtaining a list of covered benefits and the associated plan maximums than they are about providing them with the right product or service.

Top 10 Benefits Fraud Prevention Tips

• 7. Members should be aware that when offers of incentives

are made it could be a case of being “too good to be true”. Someone in the system will likely be paying for those incentives

• r free services perhaps through hidden fees or built-in costs.
• 8. Members should shop around and ask questions to ensure

the health care provider has the appropriate credentials for the services they are receiving or are contemplating to receive.

Top 10 Benefits Fraud Prevention Tips

9. When searching for needed products/services, members should be wary of providers who first ask if they have insurance. They plan may end up paying more for the same service/goods than someone who does not have insurance. 10. Employers should develop and communicate a policy whereby they would terminate any employee who knowingly and fraudulently submitted a claim. This policy should be stated clearly in the organization’s personnel manuals.

Premier Health & Benefits advisors offer assistance with identifying fraudulent activity under your program through our captioned audit processes. We also offer customized educational employee messaging services. Contact one of our representatives: Team Leads: Charles Boldt, Partner – 705.733.4492

cboldt@phbenefits.com

Brent Dufton, Partner – 705.305.4851

bdufton@phbenefits.com