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Fraud, Waste and Abuse

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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.

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.

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.
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Confidential Reporting Options

  1. Hotline:
    Call the BCBSAZ confidential hotline to report suspected fraud, waste and abuse. You may request to remain anonymous.
    (602) 864-4875 or (800) 232-2345, ext. 4875
    Note: Hotline is available Monday through Friday from 8:00 a.m. to 4:30 p.m. and messages can be left at any time.
  2. Online Reporting Tool:
    Click here to begin your confidential report.
Online Reporting Tool

More Information for Providers

Common Examples of Healthcare Fraud, Waste and Abuse:

  • 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 excessive 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.
  • Falsifying signatures or medical records to support misrepresented services or supplies.
  • Unbundling services to unlawfully increase medical payment.

Tips for Protecting Your Practice

  • Keep your provider ID and DEA numbers confidential and don't allow other providers to bill their services under your number (unless you meet the requirements for incident-to billing).
  • Keep prescription pads in a secured location to prevent theft and be alert for forgeries.
  • If you have delegated billing functions to an employee or billing service, have a process in place to ensure billing reflects services provided.
  • Conduct internal audits to promptly detect billing inaccuracies.
  • Carefully review and document the medical necessity of services or supplies provided.
  • Establish a process to keep up with benefit and policy changes.
  • Do not waive deductibles and/or coinsurance.
  • Establish a process to verify that the patient name on the insurance card matches a photo ID.
  • Watch out for patients who are "doctor shopping" to obtain controlled substances.