Protect your Plan against Fraud

March 22, 2021

When fraud occurs against the PSHCP, it is against the Plan Sponsor, the Government of Canada who assumes full liability for the payment of all costs related to the operation of the Plan and the payment of claims. Benefits fraud increases costs to your benefit plans, which may result in future cuts to benefits coverage.  As the Plan Administrator, Sun Life is committed to identifying and preventing fraud. Using industry leading anti-fraud technology, significant measures are taken to protect both the Plan and its membership. This involves a robust set of audit components that detect billing irregularities and anomalies in pharmacy, hospital, medical practitioner as well as claims submitted by members.

What is fraud?

Fraud involves the intentional use of deception to obtain personal gain and services at the expense of the Plan. The main types of benefit fraud are:

  • Plan member fraud: for example, when a plan member submits claims for services not received.
  • Provider and plan member collusion fraud: for example, when healthcare providers and plan members submit claims for prescription eyewear when non-prescription designer sunglasses were received.

How can you protect your Plan?

  • Avoid sharing Plan details: Be wary of providers and retailers who attempt to sell you more than is medically necessary.
  • Review your claim statements for any irregularities to ensure you received the services or products that were submitted for reimbursement.
  • Check your receipts: Ensure that the names, services, and dates printed on your receipts are correct and that they indicate that the products or services have been paid in full.
  • Ensure your healthcare provider is not on the Delisted Provider list. We recommend that you check this list regularly to make sure the services are eligible under the Plan. When a provider or a clinic is on the Delisted Provider List, claims for any services or products they provide are no longer processed or paid. To do so, visit mysunlife.ca/pshcp:
    • Go to the Benefits section;
    • Look for Lumino Provider Search and Browse by specialty or Search by name.
  • Report suspected fraud: If you are suspicious of any activity regarding your Plan – please contact Sun Life’s Fraud Tip Line. Call toll free at 1-888-882-2221 or send an email at clues@sunlife.com.