Medical Billing Fraud

Medical Billing Fraud is Rampant

Blue Cross Blue Shield estimates that 1/3 of every dollar Americans spend on health care services goes to cover waste and fraud. That's more than we spend on national defense and we spent nearly 600 billion on our defense.  Much of this fraud is billing fraud and chances are your own doctor is one of the thieves.

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?
• Protecting Members
• Financial Impact
• Who's Doing It?

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

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

 

The Costs of Health Care Fraud

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%.

 

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
Office of Personnel Management
Office of Inspector General
U.S. Postal Service
Federal Trade Commission
U.S. Postal Inspection Service
Food and Drug Administration
Department of Health and Human Services
Office of Inspector General
Department of Labor
National Health Care Anti-Fraud Association
Coalition Against Insurance Fraud
Association of Certified Fraud Examiners
State Attorneys General
State Departments of Insurance
State and Local Police Departments White Collar Crime Units
State Medical Licensing and Disciplinary Boards