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FRAUD NEWSLETTER

December 17, 2020

Benefits Fraud is Stealing!

Since inception of the OSSTF Benefits Plan over $100,000 of proven fraudulent claims have been reported to the OSSTF ELHT Board of Trustees. These reports have been related to plan members who have intentionally submitted false or misleading information on health or dental claims.

In each of these cases, repayment was required, and the member lost their right to online claims processing.

What is health and dental benefits fraud?

Benefits fraud occurs when you intentionally submit false or misleading information for the purposes of financial gain, and it can take on many forms, including:

  • Billing for health or dental benefits that were not received
  • Billing inflated costs for eligible expenses that were higher than actually paid to the benefits provider

Benefits fraud affects us all. You might think that benefits fraud is just stealing from Manulife, our benefits provider; but in fact, the fraud is against the OSSTF ELHT. The OSSTF Benefits Plan provides meaningful life, health and dental benefits to you and your family members. We want this plan to continue to be available to you and your family members for years to come. False health and dental claims can put the OSSTF ELHT benefits at risk for all OSSTF members. They increase the costs of the plan, which can result in a reduction to the benefit levels and/or higher member contributions towards the benefits.

It is important that you understand that whether these fraudulent claims are submitted because you need extra money or want more treatments than the plan covers, the submission of these claims is fraudulent. The OSSTF ELHT Board of Trustees must take action to protect the long-term sustainability of the plan.

How were these claims identified?

ALL submitted claims go through advanced analytics to identify potential fraudulent activity.

The staff and systems utilized for the claims handling of the OSSTF Benefits Plan are constantly being monitored with various detection tools including:

  • Fraud recognition training
  • Advanced data analytics
  • System controls
  • Drug management
  • Specialized staff

OSSTF Benefits Fraud Policy

The OSSTF Benefits fraud policy is posted on www.osstfbenefits.ca. This policy is intended to protect access to affordable benefits for all of you and your families.

https://www.osstfbenefits.ca/wp-content/uploads/2018/09/OSSTF_ELHT_Fraud_Policy.pdf (109kB PDF)

As indicated in the Fraud Policy for members who commit fraud relating to OSSTF Benefits, actions recommended by the Board may include but are not limited to:

  • Suspension of, or permanent removal of access to online claims
  • Referral of all future claims to Carrier Risk Management for monitoring and verifications
  • Pursue overpayment through Carrier
  • Filing of a statement of facts with law enforcement
  • Civil litigation

Fraud is a criminal offence. Action is taken by the OSSTF ELHT for each and every fraudulent claims situation reported to the Board. Fraudulent claims always have to be repaid by the involved member, permanent removal of access to online claims is always processed, and strong consideration is always given to the reporting of fraudulent activity to the police. If a member is charged and convicted of fraudulent claims activity, this will need to be declared by the member as part of the annual offence declaration which may lead to discipline from their employer up to and including possible termination.

Manulife’s list of providers not covered

Fraud may also be committed by service providers. Claims from providers that are deemed by Manulife to be fraudulent will not be approved. Manulife maintains a list of providers not covered. To view this list, you can log in to OTIP’s secure member site at www.otip.com and go to the Wellness centre in My Claims. Members can also call OTIP Benefits Services at 1 866 783 6847 to inquire about these providers. We encourage you to check this list periodically to minimize delays to your claims.

Detecting benefits fraud

Benefits fraud is not always easy to spot, especially when it is suggested by someone you trust. Look for these warning signs and report them if they occur:

  • Feeling pressured by your health or dental service provider to get unnecessary products or procedures
  • Being encouraged to claim products or services that you didn’t receive, or are not covered by your plan
  • Health or dental service providers who seem more concerned with the details of your insurance coverage than providing the right product or service
  • Feeling encouraged to include incorrect or misleading information on a claim
  • Being asked to sign a blank claim form (often completed later with misleading information)
  • Health or dental service providers who use your plan membership information to charge for products and services you never received
  • Being offered cash or other incentives in exchange for your policy information

How to use your benefits appropriately

Understanding how to use your benefits appropriately can help you guard against potential fraud. Here’s how:

  • Familiarize yourself with your benefits plan and the limits of your coverage
  • Keep your personal benefits plan access information in a safe place and don’t lend your card to anyone
  • Check your explanation of benefits and receipts to make sure they reflect the services you actually received
  • View list of providers not covered under the Wellness centre in My Claims
  • Be sure to understand the treatments, services and products being prescribed to you—don’t be afraid to ask questions!

Do you suspect fraud?
If you suspect that someone you know or a service provider may be committing fraud, you can confidentially report it to comments@osstfbenefits.ca, or Manulife (in care of
OTIP) at 1-877-481-9171 or gb_investigative_services@manulife.com.


The information in this document is provided by OSSTF Benefits for general information only. OSSTF Benefits endeavours to have all information current and accurate. We make no representations or warranties of any kind, express or implied, about the completeness, accuracy, reliability, or suitability of the information included. All information is subject to change without notice.


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