Using your laboratory benefits effectively to prevent fraudulent practices and abuse
The Investigative Services department at iA Financial Group is committed to protecting your plan and plan members. Therefore, we recently conducted an in-depth review of claims submitted under the laboratory benefit and found the following questionable practices:
- Some laboratories mark invoices as paid, in order to facilitate reimbursement of the claim under the health insurance plan, prior to receiving the funds from the member. It is clearly specified in the contract that a member cannot receive reimbursement for a claim before he/she has officially paid for the service in question. Furthermore, the total amount of the bill can be inflated to ensure the out-of-pocket portion (coinsurance) is paid by the health plan. This practice constitutes fraud. Under no circumstances should a member be reimbursed 100% of the benefit if the contract stipulates a coinsurance lower than 100%.
- Due to the provincial health system in Quebec, it is often difficult for your employees to have easy access to an attending physician. During our investigation, it came to light that a number of clinics had certain doctors who would agree to become the employee’s regular attending physician as long as the employee underwent a series of preventive tests. The receipts would then be submitted as diagnostic tests, which is not permitted. If your contract does not cover preventive tests, then they are not eligible for reimbursement. We found that once this practice is in place, these ineligible tests are re-submitted on an annual basis.
- Some clinics outsource their laboratory work and then top up the amount on their invoice to cover their administration costs. These types of expenses are not eligible under all contracts.
WHAT CAN YOUR EMPLOYEES DO TO MITIGATE FUTURE FRAUD/ABUSE OF THIS BENEFIT?
While you are offering benefits to your employees, they must use them the way they were intended. Here are some important things for plan members to look out for when submitting claims under the laboratory benefit:
- They should not enter into an arrangement with the laboratory whereby they are paying for the benefit after they have received their reimbursement from iA.
- If a laboratory is offering them a discount to cover the cost of the coinsurance, they should advise the laboratory that this is a fraudulent use of their benefits.
- They should question any laboratory that indicates they can give them a receipt that will ensure their preventive tests are covered even if their contract indicates otherwise. This is considered fraud. If they are submitting receipts for tests that are not a result of a particular condition, these are most likely preventive tests and therefore not covered by their plan.
- They should always ensure they are submitting the laboratory invoice and not an invoice from the clinic. That way they are able to determine if they are being charged for administrative fees.
We strongly suggest that you pass along this information to all your employees in Quebec. You will find below a communication about this matter ready to be sent to your employees. Feel free to send it as is, or copy the text and send it using your own letterhead.
Important notice to participants: Open the PDF file here.
WHAT IS iA FINANCIAL GROUP DOING TO HELP PREVENT FRAUDULENT USE OF THE LABORATORY BENEFIT?
- iA Financial Group will not pay for claims that do not have a doctor’s and laboratory name indicated on the receipt.
- iA Financial Group will not pay for preventive tests that are submitted as diagnostic tests. To determine the validity of the tests, iA may request supporting documentation.
- iA Financial Group may require proof of payment (this includes validating the payment with the laboratory). Therefore all proofs of payment must be kept for one year.
If you have any questions or concerns regarding this communiqué, please contact your benefits advisor or your iA Financial Group account executive.