Fraud can represent up to 10% of health spending in Canada.[i]
Incorrect information, over-billing or over-use, fraud has a direct impact on group insurance plans.
Groupe Premier Medical ensures that the interests of its members are treated accurately and honestly. We therefore review claims to highlight unusual trends and claims. Any suspicious case is immediately reported, and a sound investigation process is initiated. To that effect, GPM, has developed prevention programs that anticipate potential fraud based on three types of data collection:
Internal Audit: Based on their experience, our specialists and consultants have been able to develop powerful tools that detect and counter fraudulent activities.
In-depth analysis: When in doubt, we initiate a comprehensive process from healthcare provider profiling to verifying the participant’s claims’ history. This analysis allows us to detect the existence of networks between service providers and participants, and identify suspicious behavior.
Relevant data: We gather all data required for effective analyses. Any support document submitted with claims is subject to detailed verification, and a validation with the service provider is done if needed to identify or rule-out potential fraudulent activity.
We take action:
Once a problem has been identified, GPM works to get reimbursement for amounts paid based on fraudulent activities, to apply penalties as required, and depending on the situation, notify regulatory bodies of service providers who have participated in such activities.
At GPM, we make every effort to protect the integrity of our clients’ plans and extend the best services to administrators and participants alike.
[i] Canadian Association for Fraud Prevention in Health Care.