Fraud Prevention
At ASEBP, we strive to protect our covered members and employers from benefits fraud and plan abuse. After all, plan abuse impacts costs and coverage for all of us. We are committed to being your trusted advisor and take a zero-tolerance approach when it comes to plan abuse and misuse. Our goal is to ensure the continued viability of our plan so we can continue to support you and your family on your health journey.
Our Approach
Monitoring and Advanced Analytics
Using robust systems, large amounts of data can be analyzed at any given time. This data is routinely reviewed to ensure claims accuracy, and we have implemented measures to detect unusual claiming patterns and anomalies that could be related to fraud and abuse of benefits.
At the click of a mouse, a vast number of sophisticated reports can be produced that have been built to identify and set off warnings of potential claim abuse.
Benefit Assurance Team
Our Benefit Assurance team, alongside our external stakeholders, is dedicated to monitoring and analyzing data, conducting audits and reviews on claims and determining the most suitable action against cases of fraud and abuse.
Providers Feature
We provide an eligible service providers list and an ineligible providers list on My ASEBP or on the Mobile App to help our members make informed decisions when seeking a new service provider.
When using this tool, there are a few things to keep in mind:
- The eligible providers list contains only providers located in Alberta, and those that have had claims processed by ASEBP in the last six months. This feature is for informational purposes only. Recommendations are provided by your peers, ASEBP covered members. ASEBP does not endorse or recommend specific service providers.
- The ineligible providers list contains a list of providers that ASEBP will not accept claims from due to non-compliance with claiming standards. This means if you go to an ineligible provider or clinic for a product or service, ASEBP will not reimburse you under your Extended Heath Care (Drugs, Other Medical Services & Supplies and Travel Emergency), Dental Care or Vision Care coverage.
Anonymous Reporting Tools
We offer our members, and any member of the public, anonymous reporting tools to help report suspicious activities.
What Is Benefits Fraud and Abuse?
Fraud and abuse of benefits refers to intentional abuse, misuse or overuse of the benefit plan for personal gain. Some examples include:
- Transferring coverage between covered members (e.g., claiming a service under a dependant's benefit coverage when the service was for you)
- Accepting incentives or gifts from providers (e.g., getting a free pair of shoes or a purse with orthotics)
- Claiming benefits that are not covered by the plan as an eligible benefit (e.g., receiving a spa treatment and claiming it as a therapeutic massage)
- Service providers claiming for services that are not medically necessary or were not provided
- Misrepresentation of conditions in a disability claim
Fraud and abuse of benefits is unlawful and affects everyone. It has lasting impacts, including higher premiums, suspension of benefit coverage or worse. By working together, we can keep your benefits safe and make sure you get access to a vast array of benefits for generations to come.
Be Part of the Solution
Prevention starts with you. Make smart choices when seeing a service provider and submitting accurate claims information. Learn from the tips below to help protect you and your benefits from plan misuse and abuse.
- Always ensure that your and your dependants' personal information (including coordination of benefits information) is up to date with ASEBP and your service providers.
- Choose your health provider carefully. Before visiting a service provider, search the individual provider or clinic name under the Service Providers tab online at My ASEBP or on the Mobile App to determine their eligibility status.
- Do not accept incentives such as cash, gift cards, or material items from service providers. Only purchase products or services that are medically necessary.
- Never sign blank claim forms. Only sign claim forms once you have confirmed they are complete and accurate.
- Always look over your receipt information (where applicable), and when claims are being direct billed, be sure to ask for a printed copy of your Explanation of Benefits (EOB). This will provide you with your claim details. If you notice any discrepancies, be sure to have your provider contact the Provider Services department to correct the claims information.
- Only share your ASEBP ID number with your service providers.
- Regularly check your claims history online on My ASEBP or on the Mobile App to make sure all claim details are correct.
- Do not hesitate! Report any suspicious activity so we can conduct a proper review.
Share and Protect
Have you noticed any suspicious or fraudulent activity?
- Report it anonymously through our online form
- Call our confidential hotline toll free at 1-844-827-TIPS (827-8477)
- Email us at tips@asebp.ca
