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Healthcare Fraud

Healthcare fraud is more damaging than you probably imagine. Though committed by a very small number of people, healthcare fraud affects every patient, doctor and hospital in the country, wasting billions of dollars every year. A goal of the Blue Cross and Blue Shield Service Benefit Plan is to preserve health care quality and affordability. That's why we're working with hospitals, doctors, consumers and, where appropriate, law enforcement agencies to identify and stop healthcare fraud.

What is healthcare fraud?

Everyone makes the occasional mistake, especially in an industry as complex as healthcare. Rest assured, inadvertent errors are not considered fraudulent.

Healthcare fraud is the intentional, unlawful misrepresentation or deception for the purpose of gaining unauthorized benefits - financial or otherwise. Abuse is defined as reckless conduct that goes against and is inconsistent with acceptable business and/or medical practices resulting in greater reimbursement.

Fraud and abuse can compromise patient safety and future care. One example of patient harm is unnecessary, sometimes invasive, medical procedures. A provider who enters false codes on a patient for purposes of greater reimbursement leaves the patient with a false diagnosis being associated with their or their family's medical history.

Common examples of medical and pharmacy healthcare fraud

Fraudulent schemes are limited only by the imagination of the individual committing the fraud. Common examples are:

  • Billing for services not rendered Billing for services not rendered -- billing the insurance company for services (e.g., office visits, checkups, physicals, etc.) that were never provided to the member.
  • Billing for medically unnecessary services Billing for medically unnecessary services -- billing the insurance company for services that were not necessary in the treatment of the member.
  • Misrepresentation of services Misrepresentation of services -- billing the insurance company for services that do not accurately represent the actual services provided.
  • Misrepresentation of identity Misrepresentation of identity -- representing oneself or others as if they meet the criteria for health insurance coverage or are the actual person who is covered by the plan.
  • Ineligible dependents Ineligible dependents -- representing oneself or others as if they are eligible dependents meeting the criteria for health insurance coverage (e.g., maintaining coverage for ex-spouse).
  • Altered claims (medical/prescription) Altered claims (medical/prescription) -- changing the original claim or prescriptions (e.g., changing the quantity from 30 to 130).
  • Thin air scripts Thin air scripts -- pharmacists billing the insurance company for prescriptions that were never written by a doctor or never received by the member.
  • Shorting Shorting -- pharmacists billing for a larger quantity of a drug when in fact they dispensed a lesser quantity.
  • Doctor Shopping Doctor shopping -- obtaining narcotic prescriptions from multiple doctors through deceit.
  • Falsification of application (SF 2809) Falsification of SF 2809 -- including false / fraudulent information on the form that would otherwise prohibit coverage (e.g., listing a girlfriend as a spouse).

What the BCBS Service Benefit Plan is doing about fraud

According to the National Health Care Anti-Fraud Association, healthcare fraud accounts for at least 3 percent of overall healthcare spending, leading to losses of over $60 billion in 2005. And with healthcare costs going up every year, so too are the costs of healthcare fraud.

The Blue Cross and Blue Shield Service Benefit Plan invests in numerous programs that raise the industry standard for healthcare fraud prevention.

  • Each Blue Cross and Blue Shield company has its own investigative unit that actively pursues fraudulent activities and the recovery of monies lost to fraudulent or abusive activities.
  • Computer and software technology analyzes millions of claims for patterns of suspicious billing activity.
  • The Blue Cross and Blue Shield Anti-Fraud Task Force works with medical professionals and government agencies to uncover fraud in multiple states.
  • Our Blue Cross and Blue Shield Anti-Fraud Hotlines receive more than 80,000 calls a year.

Fraud prevention and you

Blue Cross and Blue Shield is committed to protecting our members, healthcare providers, and federal benefits against healthcare fraud. But we can't stop healthcare fraud alone. We need the participation and support of institutions and individuals.

How you can help

  • Think of your healthcare card as being as valuable as your credit card. If you think your card was stolen, you should contact your local Plan and request a new contract ID when you request a new card to prevent unauthorized use.
  • Carefully review your Explanation of Benefit (EOB) notices and medical bills and verify dates, reasons and costs to ensure that you and/or the Service Benefit Plan is being billed for services that were actually received.
  • Be aware of "free" services. If patients are asked to provide their insurance card, the service may not be free and could be fraudulently charged to them or their insurance company.
  • Avoid using professionals who tell you they know how to bill for uncovered services.
  • Do not leave your ex-spouse on your contract after your divorce has been finalized. If you have been ordered by the court to cover your ex-spouse for an extended period of time you must first terminate your ex-spouse from your contract which must be proven via copy of divorce decree and provide new coverage for them under a separate policy or contract.
  • Do not include anyone on your contract that is not legally considered your spouse or dependent.
  • Maintain clear and accurate records relating to your medical history including dates of office visits and prescriptions.

These efforts are making a difference. With your help, we can do even more to preserve healthcare quality and affordability.

If you suspect fraud:

Call

The FEP Fraud Hotline at 1.800.337.8440

Write

The United States Office of Personnel Management
Office of the Inspector General Fraud Hotline
1900 E Street, NW
Room 6400
Washington, DC 20415-1100

Click here to contact the Blue Cross and Blue Shield Plan in your area

When reporting suspicions of fraud, please be sure to include the following information:

  • Your name
  • Your contract number, if applicable
  • The date and time of your call
  • A telephone number where you can be reached and the best time to call
  • Email address
  • Be sure to clearly identify the person or entity you are calling about
  • The service dates in question
  • State briefly the nature of your concern or complaint

Medical Identity Theft

The Federal Trade Commission (FTC), the nation's consumer protection agency, recently published the free consumer brochure, Medical Identity Theft. The six-page publication explains how medical identity theft occurs, how it differs from traditional identity theft, offers tips to minimize your risk and how to recover should you experience a theft. To order copies in bulk, please visit bulkorder.ftc.gov 

Facts for Consumers(html version) 

Page last updated: January 02, 2013

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