What is health insurance fraud?

Fraud is defined as wrongful or criminal deception intended to result in financial or personal gain. In the Health Insurance industry, this would be best described as a dishonest act or a deliberate deception where a person received a benefit payment they are not entitled to, or the use of false and/or misleading information to claim a benefit.

Fraud can take many forms and impacts us all. Every case of fraudulent claiming contributes to operating costs which can lead to higher premiums. HIF has a zero-tolerance approach to all types of fraud.

Some examples of fraud may include:

  • Use of a false name to get a membership or claim benefits.
  • Submission of altered receipts or falsifying documents.
  • Inaccurate recording or claiming of treatments and services.
  • Claims for services or treatments that did not occur.
  • Overcharging or upcoding resulting in higher benefits paid. 
  • Allowing a non-member to use your HIF membership card.

How does HIF prevent and detect fraud?

To ensure member funds are protected, we proactively identify fraud through various mechanisms, including ongoing risk-based claim verifications.  We also endeavour to respond to all reports of fraudulent conduct or activities. 

Our Fraud team utilises a number of different ways to detect unlikely claiming patterns and billing discrepancies, to both prevent and recover losses on behalf of our members.

How can you help?

Here are some ways you can help to prevent fraud:

  • Keep your HIF membership card safe and your information confidential. 
  • Never leave your HIF membership card with anyone, even a Provider (treat your membership card as you would a credit card).
  • Report your lost, stolen or misplaced membership card to us immediately.
  • Review all details on your receipts to ensure you have been billed correctly and for the right services.
  • Regularly change your password via our Online Member Centre.
  • Frequently check your claims history via our Online Member Centre.
  • Alert HIF of any improper claims for benefits.
  • Make a report to tell us about anything suspicious.

How to report fraud?

HIF encourages our members, Healthcare providers and the wider community to report any suspected incidents of fraud and claims abuse. We appreciate your help in combating fraud and the information you give us will most likely assist to prevent further fraud.

Our Fraud team will review all concerns raised in confidence and protect the identity of anyone who provides information. If confidentiality is a concern, you may prefer to remain anonymous. 

If you suspect health insurance fraud, or have any concerns regarding suspicious activities, you can report this to us by completing our Online Form.