Preventing benefits fraud is a core priority for the Canadian Life and Health Insurance Association because it helps keep benefits plans accessible and affordable for the 27 million Canadians that depend on them, says Richelle Feddema, the organization’s senior manager of anti-fraud member management.
Insurers are working together through the CLHIA’s ‘Fraud = Fraud’ program, which focuses on education, data-driven detection and collaboration across the industry, she adds. “A key part of that work includes our three industry-wide collaborative tools. We have a provider alert registry, a data pooling program which analyzes de-identified claims data . . . using artificial intelligence to detect anomalies and a framework that allows insurers to collaborate on investigations. These tools strengthen insurers’ efforts by enabling them to collaborate and detect fraud earlier.”
Read: CLHIA working with insurers on suspected benefits fraud investigations
The CLHIA’s fraud programs have been highly successful because of the impact of collaboration combined with its tool that’s leveraging AI, notes Feddema. Insurers were able to analyze more than 200 million de-identified claims using AI, which generated 13,000 alerts for potential fraud.
The association has also developed a suite of educational materials tailored to different audiences, all of whom play a vital role in protecting benefits plans, she says, adding education is the foundation of its program and the CLHIA wants to continue building on that.
As part of Fraud Prevention Month, the organization released a clear, easy-to-use educational resource for plan members, focused on awareness and everyday habits that help protect benefits plans, she notes. For health-care providers, it created a fraud prevention FAQ that offers clear guidance on accurate claiming, transparent billing and collaborating with insurers.
Read: New technologies, industry partnerships stemming the tide of benefits fraud
“Our goal is to empower Canadians with the right information so they can use their benefits responsibly and with confidence, helping ensure our plans remain strong, affordable and reliable for the people that truly need them.”
Employers also play an important role in preventing benefits fraud, adds Feddema, suggesting they promote responsible benefits use and encourage employees to understand their coverage, review their claims and protect their personal information. “[Proper communications] can make a meaningful difference. Fraud prevention is about ensuring benefits are used for the care people truly need, so plans can remain sustainable and affordable for everyone.”
Beyond Fraud Prevention Month, the CLHIA will continue focusing on education and highlighting their targeted materials by sharing them with health-care providers and continuing to express the importance of fraud prevention for everyone involved.