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Fraud, Waste, and Abuse

About Healthcare Fraud, Waste, and Abuse

Member Alerts

Learn about current scams and how you can keep your personal information safe.

Blue Cross Blue Shield of Arizona (AZ Blue) has a Special Investigations Unit dedicated to investigating allegations from anyone suspecting fraud, waste, and abuse.

According to the Centers for Medicare & Medicaid Services (CMS) the financial losses due to Medicare fraud, waste, and abuse is estimated to cost taxpayers billions each year.

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.

How to protect yourself from Medicare fraud, waste, and abuse:

  • Do not give out your personal information including your social security number, Medicare number, and/or AZ Blue identification number to anyone you do not know.
  • Do not consent to any solicitation of free medical services that require you to submit your personal identification numbers without checking with AZ Blue.
  • Do not release personal or health information to callers you do not know who are requesting to send you products in the mail.
  • If you have a question or concerns about a service, prescription, or product you received, always check with your primary care physician's office, or call AZ Blue Member Services at 1-800-446-8331, TTY: 711 8:00 a.m. to 8:00 p.m., Monday - Friday from April 1 to September 30; and 7 days a week from October 1 to March 31
  • Review your monthly explanation of benefits statements to make sure they match the visits you received the month prior.

Common examples of fraud, waste, and abuse:

  • Billing your health plan for services you did not receive
  • Billing your health plan for prescriptions or products you did not approve of or receive
  • Providing incentives such as waiving your copay or other out-of-pocket costs to entice you to visit their office or use their pharmacy
  • Showing up unscheduled to your home to offer you medical supplies, products, or services

How you can report concerns

For more information about Medicare fraud, go to StopMedicareFraud.org. If you suspect healthcare fraud, report it to the Centers for Medicare & Medicaid Services (CMS) at 1-800-MEDICARE (TTY: 1-877-486-2048) 24 hours a day, 7 days a week, or call the HHS Office of the Inspector General at 1-800-447-8477 (TTY: 1-800-377-4950). You can also visit https://www.medicare.gov/basics/reporting-medicare-fraud-and-abuse to learn more.

You can also report suspected fraud, waste, or abuse to the Blue Cross® Blue Shield® of Arizona Special Investigations Unit by emailing SpecialInvestigationUnit@azblue.com or by calling the confidential Fraud Hotline at 1-800-232-2345, ext. 4875 or 1-602-864-4875.

To confirm information about your plan or your providers, we are happy to help. You may call Member Services at 1-480-937-0409 (in Arizona), toll-free at 1-800-446-8331 (TTY: 711) for Medicare Advantage. We are here 8 a.m. to 8 p.m., Monday through Friday from April 1 to September 30; and 7 days a week from October 1 to March 31.

    Blue Cross® Blue Shield® of Arizona (AZ Blue) is contracted with Medicare to offer HMO Medicare Advantage plans. Enrollment in AZ Blue plans depends on contract renewal.

    You are eligible to enroll in a AZ Blue Medicare Supplement plan if you are age 65 or older, entitled to Medicare Part A, and enrolled in Medicare Part B, and you live in the plan service area. You must continue to pay your Medicare Part B premiums (and Part A, if applicable), if not otherwise paid for by Medicaid or another third party. During the first six months when you are age 65 and also enrolled in Medicare Parts A & B you cannot be denied a Medicare Supplement plan when you apply for one, regardless of health status.

    Health Choice Pathway HMO D-SNP is a Health Plan with a Medicare contract and a contract with the state Medicaid program. Enrollment in Health Choice Pathway HMO D-SNP depends on contract renewal. Health Choice Pathway Member Services can be reached at 1-800-656-8991, TTY: 711, 8 a.m. to 8 p.m., 7 days a week.
    Member Services can be reached at 480-937-0409 (in Arizona) or at our toll-free phone number at 1-800-446-8331 (TTY users should call 711). Hours are 8 a.m. to 8 p.m., Monday through Friday from April 1 to September 30; and 7 days a week from October 1 to March 31. Member Services also has free language interpreter services available for non-English speakers.

    OptumRx® is an independent company providing prescription mail order services.

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    Last Updated 01/01/2025