Since its inception on January 1, 1994 The Benefits Trust (benefits administrator for The Builders Benefits Plan) has been committed to professional, personalized service. Our purpose is to appropriately administer the employee benefits plans of our member employers according to their written benefits promise, and to account individually for their funds placed in trust.
We are committed to maintaining the integrity of the benefits promise our clients make to their employees.
The Benefits Trust is continually fostering relationships with relevant members within the insurance community. We are a corporate member of the Canadian Health Care Anti-Fraud Association (CHCAA). We learn much from our peers and we appreciate the opportunity this organization affords us. We work with the industry to combat healthcare fraud by sharing our experiences and by having open lines of communication. We make a point of pursuing relationships with the regulatory associations of the many practitioners whose services we cover. A working relationship with these bodies expedites the resolution of any issues that arise with their members.
The first step in the prevention of fraud begins with the member. Claim forms must be signed by the member in order to be processed except in specific situations (such as electronic dental submission). The member ultimately is responsible for the services claimed. If they are signing a blank claim form and leaving it with the service provider to submit, they may be complicit in a fraudulent act.
Every single claim processed by The Benefits Trust is checked by a trained claims adjudicator. Our adjudicators are trained to identify specific cues and unusual claiming behaviour. Claiming behaviour is tracked for suspicious activity in three ways: by member, by group and by service provider. If a claim is deemed suspect in any way, it is escalated to a fraud specialist for further investigation. Claims are tracked over time and often will reveal past indiscretions.
Our fraud specialists conduct a thorough audit of the member’s file and claim history and in many cases the claims history of the service provider. During the course of the audit, we will often contact the member and the service provider for confirmation of services rendered. We conduct both random and targeted audits to ensure that the services being provided are medically necessary. Where necessary, the regulatory body is consulted and complaints are registered. In cases where fraud can be definitively be shown, the employer and law enforcement may become involved.