Blue Cross and Blue Shield Service Benefit Plan.
News & More: Patient Safety.
The Service Benefit Plan participates in many activities that help to ensure patient safety.
Use the links that follow or scroll down to access articles and program summaries that focus on patient safety.
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. Originally published in May 2008. Resources include www.bcbs.com.
Preventing Medical Mistakes.
A report from the Institute of Medicine estimates that up to 98,000 Americans die every year from medical mistakes in hospitals alone. That’s about 3,230 preventable deaths in the Federal Employees Health Benefits (FEHB) Program a year. While death is the most tragic outcome, medical mistakes cause other problems such as permanent disabilities, extended hospital stays, longer recovery periods, and even additional treatments.
Ask Questions.
By asking questions, learning more and understanding your risks, you can improve the safety of your own health care and that of your family members. Here are some simple steps for you to take:
1. Ask questions if you have doubts or concerns.
• Ask questions and make sure you understand the answers.
• Choose a doctor with whom you feel comfortable talking.
• Take a relative or friend with you to help you ask questions and understand answers.
2. Keep and bring a list of all the medications you take.
• Bring the actual medicines or give your doctor and pharmacist a list of all the medicines that you take, including non-prescription or over-the-counter medicines.
• Tell them about any drug allergies you have.
• Ask about any risks or side effects of the medication and what to avoid while taking it. Be sure to write down what your doctor or pharmacist says.
• Make sure your medicine is what the doctor ordered. Ask the pharmacist about your medicine if it looks different than you expected.
• Read the label and patient package insert when you get your medicine, including all warnings and instructions. Under the Service Benefit Plan, we have a Patient Safety and Quality Monitoring (PSQM) Program for prescription drugs. This program is designed to promote the safe and appropriate use of medications. It uses safety checks for usage precautions, drug interactions, drug duplication, excessive use, and frequency of refills before your prescription is filled.
• Know how to use your medicine. Especially note the times and conditions when your medicine should and should not be taken.
• Contact your doctor or pharmacist if you have questions. Both our Retail Pharmacy Program and our Mail Service Pharmacy Program have pharmacists available to talk to you about your medications. You can call the numbers on the back of your ID card for assistance.
3. Get the results of any test or procedure.
• Ask when and how you will get the results of tests and procedures.
• Do not assume the results are fine if you do not get them when expected, be it in person, by phone, or by mail.
• Call your doctor and ask for your results.
• Ask what the results mean for your care.
4. Talk to your doctor about which hospital is best for your health needs.
• Ask your doctor about which hospital has the best care and results for your condition if you have more than one hospital to choose from to get the health care you need. You can also go to our online Provider Directory and access Review Hospital Profiles for quality information about hospitals in your area.
• Be sure to understand the instructions you get about follow-up care when you leave the hospital.
5. Make sure you understand what will happen if you need surgery.
• Make sure you, your doctor, and your surgeon all agree on exactly what will be done during the operation.
• Ask your doctor, “Who will manage my care when I am in the hospital?”
• Ask your surgeon:
• Exactly what will you be doing?
• About how long it will take?
• What will happen after surgery?
• How can I expect to feel during recovery?
• Tell the surgeon, anesthesiologist, and nurses about any allergies, bad reactions to anesthesia, and any medications you are taking.
More Information.
Patient safety for you and your family is important to us. You can also get more information by visiting the following web sites:
(Please Note: When you choose the links below, you are leaving fepblue.org and going to a new web site. We do not endorse these sites nor do we make any guarantees about the accuracy and content of the sites. Protection of your privacy at the new site is governed by the privacy policy of that site. Therefore, please take time to read the privacy policy of the new site.)
• www.ahrq.gov: The Agency for Healthcare Research and Quality has a wide-range of topics not only about patient safety but information on how to choose quality health care providers and improve the quality of the care you receive.
• www.npsf.org: The National Patient Safety Foundation has information on how to ensure safer health care for you and your family.
• www.talkaboutrx.org: The National Council on Patient Information and Education is dedicated to improving communications about the safe and appropriate use of medicines.
• www.leapfroggroup.org: The Leapfrog Group actively promotes safe practices in hospital care.
• www.ahqa.org: The American Health Quality Association represents organizations and health care professionals working to improve patient safety.
• www.quic.gov/report: This site provides information about what federal agencies are doing to identify threats to patient safety and help prevent mistakes in the nation’s health care delivery system.
As a Service Benefit Plan member, you also have an additional resource for all of your medical questions about treatment plans, tests and procedures. You can call Blue Health Connection or access Blue Health Connection on this web site. Blue Health Connection has a staff of registered nurses to help you with questions about your long-term or short term medical concerns. You can also access the AudioHealth Library to get more information about your health issues.
Written by Paula Spurway, Blue Cross and Blue Shield Association. Originally published in March 2008. Resource: 2008 Blue Cross and Blue Shield Service Benefit Plan brochure Section 5(h) Special Features, Section 5(f) Prescription Drug Benefits, and Page 4 Preventing Medical Mistakes.
Safekeeping Of Medicines.
Too much heat or cold, humidity and direct sunlight can lower or ruin the effectiveness of many drugs and vitamins. So, keeping them in your bathroom or kitchen may not be the right place to store them. Also, keeping them in your car or packing them in your checked luggage may also be a bad idea. It is best to store your vitamins and medications in a cool, dry place. Once you open the bottle, discard the cotton ball. It absorbs moisture and can harm your drugs.
Sometimes you will know if your medications and vitamins are damaged. They may change color, change in the way they taste, capsules may stick together and pills may flake.
It is also important to store your medications away from children. More than 1,000 children each year require medical care due to unintended medication dosage. If you have young children or grandchildren in your home or with access to your medications, including over-the-counter drugs and vitamins, you need to make sure they don't get a hold of them. The best place to store your medications is where they cannot be reached, not in an unattended purse, an open drawer, or on a table. It is a good idea to store medications in cabinets that cannot be reached by young children. If you are traveling, don't leave your medications in your suitcase if there are young children around. And you may also want to take your medications when children are not watching.
Written by Paula Spurway, Blue Cross and Blue Shield Association. Originally appeared in the May 2006 issue of Straight Talk. Resources include Blue Health Connection, see the Clinical Reference System under Safekeeping and Safe Use of Medicines, www.webmd.com, see the article Kids Vulnerable to Medicine Mishaps, www.safemedication.com, see Medications and You.
Steps To Safer Health.
Speak Up If You Have Questions.
Speak up if you have questions or concerns. Choose a doctor who you feel comfortable talking to about your health and treatment. Take a relative or friend with you if this will help you ask questions and understand the answers. It's okay to ask questions and to expect answers that you can understand and feel comfortable with.
Talk About Your Options.
Talk with your doctor and health care team about your options if you need hospital care. If you have more than one hospital to choose from, ask your doctor which one has the best care and results for your condition. Hospitals do a good job of treating a wide range of problems. However, for some procedures, such as heart bypass surgery, research shows results are often better at hospitals doing a lot of these procedures. Also, before you leave the hospital, be sure to ask about follow-up care, and be sure you understand the instructions that are prescribed.
Keep A List Of All Medicines.
Keep a list of all the medicines you take. Tell your doctor and pharmacist about the medicines you take, including over-the-counter medicines such as aspirin, ibuprofen and dietary supplements like vitamins and herbal supplements. Tell them about any drug allergies you have. Ask the pharmacist about side effects and what foods or other things to avoid while taking the medicine. When you get your medicine read the label, including warnings. Make sure it is what your doctor ordered, and you know how to use it. If the medicine looks different than you expected, ask the pharmacist about it.
Get The Results Of All Tests.
Make sure you get the results of any test/procedure. Ask your doctor or nurse when and how you will get the results of tests or procedures. If you do not get them when expected call your doctor and ask what the results mean and how they may affect your care.
Understand Any Type Of Surgery.
Make sure you understand what will happen if you need surgery. Ask your doctor and surgeon: Who will take charge of my care while I'm in the hospital? Exactly what will you be doing? How long will it take? What will happen after the surgery? How will I feel during recovery? Tell the surgeon, anesthesiologist and nurses if you have allergies or bad reactions to anesthesia. Make sure all agree on exactly what will be done during the operation.
Resource: Information provided by the US Office of Personnel Management.
Updated September 2001.
Blue Cross and Blue Shield Plans Measurements Of Quality.
Blue Cross and Blue Shield Plans are continually working to provide you with access to quality health care. One of the ways to demonstrate that we are achieving these goals is to have these efforts measured. These measurements of quality are taken in various areas in which you are directly affected, such as how effective your clinical care is, how satisfied you are with the services you receive, and how efficiently your Preferred Provider Organization (PPO) operates at all levels. To receive an objective evaluation of these processes, nationally recognized organizations are brought in to determine a PPO's ratings. These impartial organizations have set the standards for quality and performance measurements. Two leading organizations that measure PPO performance are the National Committee for Quality Assurance (NCQA) and American Accreditation Health care Commission/URAC (URAC). Both the NCQA and URAC have given an approved rating to the following Blue Cross and Blue Shield PPOs:
National Committee for Quality Assurance (NCQA).
Anthem BCBS of Virginia.
Blue Cross and Blue Shield of Massachusetts.
Blue Cross of California.
CareFirst Blue Cross Blue Shield (DC & MD).
Independence Blue Cross.
American Accreditation Health care Commission / URAC (URAC).
Anthem Midwest (Ohio, Kentucky & Indiana).
Blue Cross and Blue Shield of Alabama.
Blue Cross and Blue Shield of Georgia.
Blue Cross and Blue Shield of Missouri.
Blue Cross and Blue Shield of Oklahoma.
Resource: Information provided by the Blue Cross and Blue Shield Association.
Updated September 2003.
Prescription Drug Safety.
Ensuring Medications.
We have several programs that protect your health by ensuring medications are prescribed in accordance with generally accepted medical practice. We also ensure the safety of the medications you and your family use through drug use review.
Patient Safety And Quality Monitoring.
The Patient Safety And Quality Monitoring program, also known as PSQM, is comprised of a set of clinically aligned programs currently in place that are designed to promote the safe and appropriate use of medications. Examples of this program include:
Prior Approval — requires that approval is obtained for certain prescription drugs and supplies before they are covered. A list of drugs requiring prior approval and the forms to be completed can be found on this web site under the Pharmacy Programs feature. Your physician may return the form by mail or fax it to the address indicated on the form.
Safety Checks — before your prescription is filled, we have put in place safety and quality checks to provide information on precautions or contraindications related to other drugs, patient age and sex. In addition these checks identify drug duplications, review for excessive use of medication and for refills that are requested too soon.
Quantity Allowances — we have established specific allowances for several medications. For examples of quantity allowance medications, please refer to the prior approval feature under Pharmacy Programs feature on this web site.
Drug Use Review.
Both the Retail Pharmacy and Mail Service Pharmacy Programs review your prescriptions to monitor any problems that may occur. We look to make sure there are no problems or interactions with other medications you are using or disease conflicts. Messages about possible drug interactions are sent to the pharmacists while you are filling a prescription at a retail pharmacy and to the pharmacist filling your prescription at our mail service pharmacy.
We also make sure you are not getting refills too late or too soon. Either situation may indicate a problem or misunderstanding you are having with the instructions for taking the medication.
Education.
We educate our network pharmacists through regular newsletters to keep them informed about the Service Benefit Plan prescription drug benefits. In addition, we communicate with both your physician and you about your drugs and the availability of special programs for certain diseases.
Resource: Information provided by the Blue Cross and Blue Shield Association, Advance PCS, and Medco Health Solutions.
Updated December 2004.