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B U S I N E S S I N T E G R I T Y I N V E S T I G AT I O N S E RV I C E S

Fraud prevention awareness


Protecting your health coverage is a
full time job

To help prevent abuse and fraud, claims analysts are


trained to identify inappropriate claims such as:

As members of a group benefits plan, were fortunate


to have access to health care coverage. With increasing
costs and greater demand on the health care system,
benefits plans are something most people no longer take
for granted. And just like any other valuable personal
property, benefits plans need to be used properly so they
can continue to provide coverage that helps to support
the good health and well-being of plan members and
their families.

health care providers who are tempted to submit


false or misleading claims in an attempt to obtain
more money than they are entitled to;

Undoubtedly, the vast majority of people are honest and


ethical. But for a very small group of individuals, benefits
plans can be a tempting target as those people seek a
way to access the program and attempt to exploit it for
their personal financial gain. While Manulife Financial
has controls in place to prevent abuse, its important for
you and your plan members to be aware of this threat to
your benefits plan.

Fraud hurts everyone


In the case of Administrative Services Only (ASO) plans,
Manulife Financial receives plan members health, dental,
and other claims and using its expertise to apply the
coverage and administer the plan according to the
contract, it pays claims on plan sponsors behalf.
Some plan members may not know that their employer
ultimately funds the ASO program that pays the claims.
So if an inappropriate claim gets paid, it can lead to
increased costs for the plan sponsor, which could then
place an undue burden on the benefits coverage
available to plan members.

patients who tamper with documents in order


to obtain reimbursements for payments they
havent made;
patients who are motivated by incentives or sales
promotions to obtain services that they arent eligible
for or dont need; and
claims in which a provider and patient work
together and submit false, misleading or exaggerated
information in order to obtain payment from
the plan.
Sometimes these actions are intentional, and sometimes
they arise when employees place their trust in the wrong
people and are influenced to seek more reimbursement
than is appropriate under the circumstances. Regardless,
the plan member is ultimately responsible for all costs
submitted to the plan in his or her name.

Nobody likes a cheater


When Manulife Financial has reason to suspect a case of
fraud or abuse, we will conduct further investigation in
an attempt to recover any money that has been obtained
improperly. In cases where fraud is identified, Manulife
Financial will contact the employer to provide details of
the findings. And when the likelihood for a successful
prosecution exists, a criminal complaint is submitted to
the appropriate law enforcement agency.

A serious problem with serious


consequences
In fall 2006, a 47 year old woman was sentenced to
three years in the penitentiary after pleading guilty to
12 fraud-related charges. The charges concerned the
misappropriation of more than $100,000 from various
businesses, including former employers and two group
benefits providers. The group insurance portion of the
money obtained fraudulently was taken between 1999
and 2005 when the woman submitted false claims using
receipts that she altered or created. Evidence gathered
through Manulife Financials investigation contributed to
the fraud conviction.
This serious penalty was partially influenced by the
womans previous conviction for similar crimes. The
victims of this behaviour are many, and the costs are
borne by the insurance company, her employer, and her
fellow employees. The end result of benefits plan fraud is
higher premiums or reduced benefits, or, in some cases,
the complete loss of an affordable benefits program.

Taking responsibility for your plan


Manulife Financials website
(www.manulife.ca/stopbenefitsfraud) contains
information that will help plan sponsors and plan
members understand how their benefits plan works and
their role in fraud prevention. Plan members should keep
the following tips in mind when submitting a health or
dental claim.

Never sign a blank claim form. Confirm the


information on the form is correct when signing.
Your signature is our assurance that you received the
services being billed for.
Never submit a claim before receiving the treatment,
service, or product.
Review your claim payment statements. If you detect
errors, call the Manulife Financial Customer Service
Centre at 1-800-268-6195.
Never give anyone your plan or policy numbers.
Treat these as you would any confidential personal
information.
Make sure you understand the treatments you
receive. Ask questions if you dont.
Keep records of your appointments, treatments,
and dates.
Know what your benefits are and how your plan
works. If you have questions, start by asking your
plan administrator. Decisions are easier to make when
you understand your coverage.
If you suspect fraud or the possible abuse of
your benefits plan, your concerns can be reported
anonymously to Manulife Financial at
1-877-481-9171 or you can e-mail
gb.investigative.services@manulife.com

Its an unfortunate fact of life that we must be diligent to protect those things that
are important to us. Even though benefits plans arent something that can be locked
up for the night, we can all keep watch and do our part to help protect the health
coverage we value so highly.

Manulife Financial and the block design are registered service marks and trademarks of
The Manufacturers Life Insurance Company and are used by it and its affiliates including
Manulife Financial Corporation.

(01/2008)