Canadian HR Reporter

December 2019 CAN

Canadian HR Reporter is the national journal of human resource management. It features the latest workplace news, HR best practices, employment law commentary and tools and tips for employers to get the most out of their workforce.

Issue link: https://digital.hrreporter.com/i/1188020

Contents of this Issue

Navigation

Page 11 of 27

CANADIAN HR REPORTER DECEMBER 2019 12 NEWS Bending the benefits cost curve by fighting fraud Plan members highly value their benefits. And, plan sponsors want to offer competitive plans to attract talent and keep their employees healthy. But the threat to plan sustainability caused by health benefits fraud continues to rise for a number of reasons. Those reasons include: rising health-care costs, organized crime and limited law enforcement resources. Educating plan members is a key component in helping to prevent benefits fraud. And the benefits industry needs to look at other members involved in the fraud landscape — along with the source of new, complex schemes. The Canadian Life and Health Insurance Association (CLHIA) reported that health-care and other providers commit more than 80 per cent of suspected benefits fraud. They either do so on their own or with plan members. So, providers must be a key focus for insurance carriers. Using an intelligence-led approach and rich data collection, Sun Life tracks where plan sponsors' benefits dollars are going. This enables them to spot abnormal claiming patterns across medical and dental benefits. It also helps them to see when suspect fraudsters are targeting plans for collusion schemes. By exposing new schemes and detecting when fraudsters target benefits plans, the Sun Life Fraud Risk Management team can often prevent it from happening. Their team also help plan sponsors put policies and procedures in practice, to reduce the risk of benefits fraud. Before processing claims for a new provider or association, Sun Life verifies their credentials. And they act fast to stop accepting requests from suspicious providers — a process called delisting. If their team suspects fraud, they help their clients deal with the issue throughout the investigation and recovery process. They also help them reestablish trust within their businesses, after dealing with a fraud case. Sun Life's goal is to stop benefits fraud with a proactive approach to fighting fraud and plan abuse. They are working to bend the benefits cost curve and support plan sustainability. To learn more about Bending the Benefits Cost Curve and other innovations at Sun Life, visit sunlife.ca/ benefitsinnovations. buying a brace or a compression stocking." Often, people go to make a purchase but they don't do any research with respect to price, he says. "That's what's happening — employees are going out there and they're purchasing items and they know they're covered under the benefits plan, so they don't bother checking or doing any research with respect to price. And the industry itself has taken advantage of that." Mitigating fraud risk Another big area of focus when it comes to plan sustainability is fraud risk management, accord- ing to Bending the Benefits Cost Curve. This is about using the power of technology and fraud professionals to detect suspicious activity and delist suspect health- care providers. Benefits fraud costs insurance carriers hundreds of millions of dollars annually, according to Joseph Peter, vice-president of fraud risk management at Sun Life. "It's a symptom of the reim- bursement nature of a benefit plan where there's a lot of trust built into the system," he says. "To counteract that issue, it's really important that insurers are able to both invest in the analytics required to identify these pat- terns and issues but also have the multi-disciplinary teams re- quired to investigate." Delisting fraudulent providers is also a focus, says Peter, citing the 1,800 organizations removed from Sun Life's reimbursement list since the program's inception. "That's really proven to our management and to the employ- ers that we service that this is a serious issue and that zero toler- ance is the only way to deal with it," he says. While employers can often be sidetracked by concerns of in- dividual employees submitting false claims, it is the larger net- works of fraud that do the most damage, says Peter. "Fraudsters out there — third parties outside of the system — are taking advantage of that [trust] to coach employees on ways to get around the system, get around the controls, submit false claims, and then the parties are working together to share the proceeds." Too often, employers make it more complicated than it needs to be by failing to properly prepare internal human resources policy, says Peter. "They need to have the action plan in place… so everybody's on the same page because, ultimate- ly, the impact to that benefit plan and that employer will translate into reduced benefits and less op- portunity to help the people that really need the help because of an actual medical condition." Employers have a major role to play in supporting investigators looking into collusion schemes, says Peter. "One of the easiest ways and most important ways to do that is to really be clear with your em- ployees around what are the stan- dards," he says. "So, be clear that you do not accept fraud on the benefit plan. Treat it the same way as you would if they are walking out with boxes of supplies out of the back of the warehouse." Employees have a role to play in keeping benefits costs down, says Côté. "When an employee steals from an employer, they're really steal- ing from themselves in the long run," she says. "Because then the employer will see costs rising." It's really important to have everybody working together to continually combat this issue, says Peter. "It's not good enough just for an employer to worry about it or for the insurer to identify the issue or for the employees to try to be aware of the situation — everybody has to work together to identify it, to just stop it." Too often, employees don't understand costs involved BENEFITS < pg. 11 "When an employee steals from an employer, they're really stealing from themselves in the long run."

Articles in this issue

Links on this page

Archives of this issue

view archives of Canadian HR Reporter - December 2019 CAN