Examples of errors, fraud, and abuse

Errors, fraud, and abuse may represent up to 10% of benefits paid out

Certain healthcare professionals sometimes abuse private plans, without the insureds even knowing. Here are some examples of real situations in which you can make a difference:

Error in medications

A claim for contraceptive pills amounting to more than $900 was claimed in the pharmacy. After questioning by the CCQ, the pharmacist admitted that this was a data-entry error, as he had claimed 28 containers of 28 pills, rather than a single container containing 28 pills.

If the insured had reviewed his invoice at the cash, he would have found the error immediately in the pharmacy and thus have avoided recovery procedures.

If you have questions about your invoice, don’t hesitate to ask the pharmacist. After all, it’s your plan!

Fraud in dental care

An insured with a right to a dental exam every nine months decided to have her teeth cleaned after only six months, which made her ineligible for reimbursement from MÉDIC. The dental clinic offered the insured to invoice her for another treatment – a service not rendered – so that she could obtain a reimbursement equivalent to the cost of the cleaning. This is a fraudulent act.

After refusing this collusion, the insured contacted the CCQ to make a report. The insured’s call enabled the CCQ to intervene and identify other fraudulent situations. Blowing the whistle on this type of situation enables MÉDIC to recover money. Every action counts.

Abuse in complementary health services

All members of an insured’s family were receiving maximum reimbursement per insurance period for paramedical care. When the CCQ investigated, it found that the massage therapy provider was the spouse of the insured and that she was providing services and issuing receipts to all members of her family, including herself.

Uses of complementary health services that are abusive and not medically required lead to higher expenditures by the MÉDIC plan. Make sure you claim only the services that are medically required. Abuses will be uncovered sooner or later, and verifications are underway to money that was overpaid. If you witness such activity, try to stop the abuse or report it to the CCQ.

Take care of your plan!

Report any situation that seems suspect to the CCQ’s Customer Services, at 1 888 842-8282.