Healthcare Fraud And You

What is healthcare fraud? It is the intentional filing of a false claim for monetary gain. It is lying about your condition or the types of services provided by a hospital or physician. It is cheating by omitting information about your condition, symptoms or treatment or services when filing a claim. It is stealing. The estimated loss as a result of healthcare fraud and abuse is about $60 billion annually.

Healthcare Fraud Is A Crime

Healthcare fraud is a federal crime as well as a crime in most states. Many think healthcare fraud is a victim less crime. It is not because healthcare fraud means higher insurance premiums, higher taxes and higher cost sharing amount for everyone with health insurance.

You can be hurt as a result of fraudulent claims under your coverage involving medical care, surgery, diagnostic testing and drug therapies. Your health insurance information can be used by other individuals who file claims and create a false or incorrect claims history under your enrollment. It can cause confusion and delay your treatment just to sort out what has been happening.

What Can You Do?

First, it is important that you are aware of all the types of treatment and services you and your family receive from each physician, facility or other type of healthcare provider.

It is also important to check all the correspondence you get from Blue Cross and Blue Shield, from your Explanation of Benefits or EOB’s to letters explaining benefits payments and denials. You need to make sure that all of the services were actually provided by the physician or facility indicated.

You should protect your health insurance information. Your ID card and ID number are like a credit card and credit information. When someone not covered under your enrollment uses your ID card for medical care it is a crime.

You should never give out your Service Benefit Plan ID number to a telephone representative or door-to-door sales person. This can protect you and your family from identity theft. If the local Blue Cross and Blue Shield Plans calls you, they will know your ID number. They may ask for the last four digits just for verification, but they will never ask for the complete ID number. This is also true for your Social Security Number and other personal identification numbers. You should never share them with someone you do not know.

Finally, let us know of any changes to your enrollment, such as a recent marriage or divorce, as soon as possible. This helps us keep your personal information up-to-date.

Reporting Healthcare Fraud

To report healthcare fraud, you can call the FEP Fraud Hotline at 1.800.337.8440 or you can write to: US Office of Personnel Management, Office of Personnel Management, Office of the Inspector General, Fraud Hotline, 1900 E Street NW, Washington, DC 20005. You can also contact your local Blue Cross and Blue Shield Plan at the number on the back of your ID card.

Written by Paula Spurway, Blue Cross and Blue Shield Association. Resources include www.bcbs.com.