Fraud, Waste & Abuse

About Healthcare Fraud, Waste, and Abuse

ACA StandardHealth with Health Choice has a special investigations unit dedicated to investigating referrals and tips from anyone suspecting fraud, waste, and abuse. According to the National Health Care Anti-Fraud Association (NHCAA), the financial losses due to healthcare fraud are estimated to be in the tens of billions each year.

In fact, $2.27 trillion was spent in 2011 on healthcare for more than 4 billion claims processed in the United States. While a small fraction of those are fraudulent claims, they carry a very high price tag. Healthcare fraud is a contributing factor to higher premiums and out-of-pocket expenses for consumers. Consumers can also experience financial losses caused by unsafe medical procedures, compromised medical records, falsified claims, and stolen identity.

Fraud
Intentional misrepresentation; deception; intentional act of deceit for the purposes of receiving payments that an individual or entity is not eligible to receive.
Waste
Generally refers to over-utilization of medical services that result in unnecessary costs, misuse of resources, and that may also be inconsistent with acceptable medical guidelines.
Abuse
Deliberate ignorance or reckless disregard of the truth; conduct that goes against and is inconsistent with acceptable business and/or medical practices resulting in payments that an individual or entity is not eligible to receive.

Confidential Reporting Options

Blue Cross Blue Shield of Arizona’s Special Investigations Unit maintains a confidential hotline to report suspected fraud or abuse.
You may request to remain anonymous. Business hours are Monday through Friday from 8 a.m. to 4:30 p.m. MST. Messages may be left outside business hours.
Call us at:
602-864-4875 or 1-800-232-2345 ext. 4875

Make a Fraud, Waste and Abuse Referral

Please complete this form to report all suspected fraud, waste and abuse (FWA) cases. The Compliance Team encourages individuals to report any issues or concern - even if it is unclear whether the matter needs referred. Compliance will promptly review the matter. Individuals who report a FWA issue or concern will not be retaliated against.

Examples of Fraud, Waste and Abuse:

Member Fraud and Abuse	Provider Fraud and Abuse
Asset misrepresentation (transfer/hiding/unreported income) Residency Citizenship status Misrepresentation of medical condition Failure to report third party liability/other insurance (TPL/COB) RX abuse/drug diversion/selling medication/supplies Misuse of ID card and/or benefits Identity theft High utilization of services/abuse of benefits	Falsifying or altering claims or credentials Incorrect coding Double billing Kickbacks Fraudulent enrollment practices Fraudulent third party liability (TPL) reporting Fraudulent billing/recoupment practices Billing for services not provided Misrepresentation/substitution of services

- Doctor shopping: bouncing from one doctor to another in order to obtain multiple prescriptions, often for a controlled substance
- Including misleading information on, or omitting information from, an application for health coverage: intentionally giving incorrect information to receive benefits
- Adding an ineligible person to a contract: misrepresenting a relationship to a contract holder
- Using ID cards that belong to someone else: using another person’s insurance ID card to receive benefits
ACA StandardHealth with Health Choice knows that one of the best defenses against fraudulent activity is an alert consumer. The following tips can help you to identify healthcare fraud:
- Closely examine your “Explanation of Benefits” to make sure the service billed was the service received when you visited a healthcare provider. If there is a difference, call the healthcare provider first since it may be a clerical error
- Be cautious of free medical exams, copayment waivers, or advertisements stating, “covered by insurance.” When it sounds too good to be true, it probably is
- Take note if you seem to be paying unusually high charges for regular services
- Understand your benefits
- Think of your health insurance ID card as being as valuable as your credit card. If lost or stolen, it could be used to gain access to drugs and services that may appear on your medical history