Healthcare Fraud

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Understanding Healthcare Fraud

Patients and their medical insurance information can be exploited in various ways that result in increased costs and decreased confidence in the healthcare system. As part of our efforts to improve and protect the healthcare system, the Blue Cross and Blue Shield National Anti-Fraud Department is undertaking a nationwide campaign to share how physicians, healthcare providers and customers can help with healthcare fraud detection and prevention.

What is Healthcare Fraud?

Healthcare fraud is a federal crime under most criminal codes and consists of intentional deceit within the healthcare system for the purpose of illicit gains. Healthcare abuse is similar activity or behavior where knowing intent to obtain an unlawful gain cannot be established.

Examples of healthcare fraud and abuse:

  • Phantom claims for services or supplies that were never provided
  • Using someone else’s medical insurance information to obtain services or supplies
  • Falsifying signatures or medical records to support misrepresented services or supplies
  • Unbundling services from a group to unlawfully increase medical payment
  • Misrepresenting the location where services or supplies are provided
  • Rendering medical care without a license
  • Duplicate claim submissions

Protecting Members

In addition to the Blue Cross and Blue Shield National Anti-Fraud Department (NAFD), each Blue Cross and Blue Shield company has its own anti-fraud unit. Currently, there are over 500 employees performing anti-fraud work for the Blue Cross and Blue Shield System in an effort to make healthcare affordable and equitable.

Our investigators work alongside Federal, State and local enforcement authorities responsible for investigating and prosecuting healthcare fraud along with other public and private Fraud investigators and anti-fraud organizations.

The NAFD operates the same healthcare fraud management for federal employees and retirees of the Federal Employee Program ® as with the private sector program.

Financial Impact

Healthcare expenditures topped $2 trillion in 2008 and are expected to exceed $3 trillion by 2014. The most conservative estimate of

the amount of healthcare expenditures lost to fraud is three percent, which equates to over $70 billion annually.

That amount costs the average family of four over $200 a year above what they would pay for the honest delivery of healthcare goods and services. Losses attributed to wasteful spending, including fraud and abuse, may be as high as 30%.

Who's Doing It?

In our electronic world where personally identifiable information and personal health information have become more accessible, customers and employees of healthcare providers, insurers and any kind of business are at risk of healthcare fraud.

Healthcare fraud can be committed by:

  • Billing services
  • Institutional providers like hospitals and other care facilities
  • Laboratories
  • Medical equipment suppliers
  • Nurses
  • Other non-medical providers
  • Customers and patients
  • Pharmacists
  • Practitioners

Protect Yourself

We encourage you to follow these general guidelines to safeguard yourself from preventable medical errors and improve the quality of care you receive.

  1. After care, review your statement to verify accuracy. Learn how to read your Explanation of Benefits .
  2. Ask your doctor to explain the reason for services
  3. Report any discrepancies to your health insurance plan or payer
  4. Beware of "free" medical services, as illicit entities use this lure to obtain information
  5. Safeguard your insurance card the same as you would your credit card
  6. Report instances where co-payments or deductibles are waived
  7. Don’t give your insurance number to marketers or solicitors
  8. Never sign a blank insurance form

Report Fraud

If you suspect that healthcare dollars are being paid improperly or as a result of false or misleading information provided to a Blue Cross and Blue Shield company, notify your local Blue Cross and Blue Shield company. Our Partners

Federal Bureau of Investigation

Office of Inspector General

Department of Health and Human Services

Office of Inspector General


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