Fraud, Waste, and Abuse

About Healthcare Fraud, Waste, and Abuse

At Blue Cross Blue Shield of Arizona, we have a dedicated special investigations unit that proactively research and investigates referrals from anyone who suspects fraud, waste, and abuse. This is a crucial part of our commitment to maintaining the integrity and value of our health care system.

According to the National Health Care Anti-Fraud Association (NHCAA), financial losses due to health care fraud are estimated to be in the tens of billions of dollars each year. A conservative estimate suggests that 3% of total health care expenditures are lost to fraud, while some government and law enforcement agencies believe the loss could be as high as 10% of our annual health outlay. This means that more than $300 billion could be lost annually to fraudulent activities. While these fraudulent claims represent only a small fraction of the total, they carry a very high price tag, both financially and in how they impact our perception of the integrity and value of our health care system.

BCBSAZ encourages everyone to stay vigilant and report any suspicious activities to our special investigation’s unit. Together, we can help protect our health care system from the detrimental effects of fraud, waste, and abuse.

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.