About Health Care Fraud, Waste & Abuse
Blue Cross Blue Shield of Arizona 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 health care fraud are estimated to be in the tens of billions of dollars each year.
In fact, $2.27 trillion was spent in 2011 on health care 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. Health care 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 identify.
- Intentional misrepresentation; deception; intentional act of deceit for the purposes of receiving payments that an individual or entity is not eligible to receive.
- 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.
- 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.