Fraud, Waste, and Abuse

About Healthcare Fraud, Waste, and 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 healthcare fraud are estimated to be in the tens of billions each year.

In fact, $2.27 trillion was spent in 2011 on healthcare 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. Healthcare 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 identity.

Definitions

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.

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 "Explanation 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, copayment 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

Nondiscrimination Notice

Blue Cross Blue Shield of Arizona complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex.

Spanish: Si usted, o alguien a quien usted está ayudando, tiene preguntas acerca de Blue Cross Blue Shield of Arizona, tiene derecho a obtener ayuda e información en su idioma sin costo alguno. Para hablar con un intérprete, llame al 602-864-4884.