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Fraud and Abuse

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About Health Care Fraud & 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.

Definitions

Fraud

  • Intentional misrepresentation; deception; intentional act of deceit for the purposes of receiving payments that an individual or entity is not eligible to receive.

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.
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Report Fraud and Abuse

  • 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 8:00 to 4:30 MST. Messages may be left outside business hours.
  • Call us at:
    (602) 864-4875 or
    (800) 232-2345 ext. 4875
Report
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For Members

Common Examples of HealthCare Fraud

  • 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

Tips to Identify HealthCare Fraud

Blue Cross Blue Shield of Arizona 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 "Explanations 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, co-payment 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

For Providers

Common Examples of HealthCare Fraud

  • Billing for services not rendered: using valid patient information to make up entire claims or padding claims with charges for services that did not take place
  • Upcoding: billing for more expensive services than were actually provided, that is, falsely billing for higher priced treatment, which often requires "inflation" of the seriousness of a patient's condition
  • Providing unnecessary care: includes unneeded tests, surgeries and other services
  • Misrepresenting services: performing uncovered services but billing insurance companies for different services that are covered
  • Pretending to be health care professionals: delivering health care services without a license to do so
  • Using another provider's ID number to receive payment

Tips for Protecting Your Practice

  • Keep your provider ID number confidential and don't allow other providers to bill their services under your number
  • Keep prescription pads in a secured location
  • If someone else is authorized to bill for your services, have a process in place to make sure billing reflects services provided
  • Conduct internal audits to detect billing inaccuracies promptly
  • Establish a process to keep up with benefit and policy changes
  • Don't waive deductibles and/or coinsurance
  • Carefully review and document the medical necessity of services or supplies provided