A fifth (22 per cent) of plan sponsors said their organization has seen an uptick in benefits fraud, either by plan members, service providers or organized crime, according to the 2025 Benefits Healthcare Survey.
During a panel discussion at Benefits Canada’s 2025 Toronto Benefits Summit last week, Lancelot Lambert, regional vice-president of Ontario and Atlantic business development for group insurance at Desjardins Insurance, said benefits fraud is much more common than the results suggest.
“I view benefits fraud like a scourge in the industry: as much as we pour resources into it, it feels like it just keeps on happening,” he added, though he noted the percentage of plan sponsors reporting an increase was somewhat encouraging because it suggested the industry was detecting more of it.
Read: New technologies, industry partnerships stemming the tide of benefits fraud
Insurers are leveraging artificial intelligence and machine learning to track usage down to the provider or postal code level and identify anomalies in claims patterns, said Lambert, and they’re also beginning to share data through the Canadian Life and Health Insurance Association. Companies are also hiring private investigators and external billing experts to fight fraud, he added, with many boosting their communications efforts with plan sponsors and publicizing the names of bad actors.
Also speaking on the panel, Ayla Azad, chief executive officer of the Canadian Chiropractic Association, said she hears from the association’s members that they want to better understand what practices are considered inappropriate or fraudulent by insurers.
She noted she sees an opportunity for the insurance industry to educate health-care provider associations, particularly around grey areas where providers may not have intended to act fraudulently. The CCA has hosts webinars for members and shares the CLHIA’s resources with them.
Read: CLHIA working with insurers on suspected benefits fraud investigations
De-listing, where an insurer disallows a certain practitioner, clinic, facility or medical supplier from claims processing or reimbursement, is like “an amputation,” said Azad, noting she’s heard from association members that recognized they’d done something wrong, but did so mistakenly and sincerely wanted to address the issue.
She advocated for a path back to good standing for providers who have erred, such as paying a fine and taking a course. “That’s not in every case — sometimes we don’t engage because they did [perpetrate] fraud. But in some other cases, is there an opportunity for us to partner so we can figure it out? Because what’s happening is people are losing access to providers, communities are losing access to a clinic and we’ve heard about issues with access and people who are not able to earn a living anymore.
“We can find a mutual solution for some cases.”
Download the full 2025 Benefits Canada Healthcare Survey report here. Look for more coverage of the panel discussions analyzing this year’s results in the coming days.