This article was updated February 26, 2021.
Managing fraud can be difficult, particularly in challenging economic times. In fact, research has shown that economic hardship often impacts human behaviors in unexpected ways—one of which is an increased likelihood of fraudulent behavior—and, often times, it’s the long-term costs of fraud that get overlooked. Alberta Blue Cross® has a strict zero tolerance policy toward any fraud or abuse of the benefit plans we administer.
While fraud remains rare, we each have an active role to play in preventing it. It’s important to know what each of us can do.
How does fraud affect you?
Each time a claim is submitted to Alberta Blue Cross®, it’s validated against the rules of that specific member’s plan to determine whether it is eligible for reimbursement. If it qualifies, the claim is paid out. Fraudulent claims for products or services increases costs to benefit plans, which in turn causes premiums to increase for all customers.
What’s our approach?
We take a rigorous approach to fraud prevention. For example:
- We have a team dedicated to evaluating the nature of the claims we receive and identifying overall patterns.
- We use advanced analytics to detect anomalies that don’t fit typical claim patterns.
- Our team of experts works to identify trends and address them before they become a problem.
- We develop comprehensive plan management strategies.
- We enforce a disciplinary policy for those providers who don’t adhere to our claiming rules.
- We work with law enforcement to investigate potential fraud and plan abuse and pursue recovery of funds where applicable.
What can you do?
If you suspect any fraud involving your benefit plan, call the Alberta Blue Cross® fraud hotline toll free at 1-866-441-8477 or contact us through the Alberta Blue Cross® Fraud, Privacy and Ethics Reporting service. All information is kept strictly confidential, including your identity, and you can report fraudulent activity anonymously.
If you’re a plan sponsor, educate your employees about how to recognize fraud and report it.
Did you know that benefits fraud costs the Canadian health care industry up to $3.6 billion every year. At Alberta Blue Cross®, we’re dedicated to cutting that number down and keeping plans sustainable. Get all your questions about benefits fraud answered on our benefits fraud website. Dive into everything you need to know about benefits fraud including how it happens, what you can watch for and how Alberta Blue Cross® can protect your plan.