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Fraud

Taking a proactive stance in preventing fraud and abuse

Fraud and abuse in the health care system is a serious problem that has an impact on all health care payors and affects every person in the country.

The U.S. General Accounting Office reports that according to industry estimates, health care fraud and abuse accounts for up to 10 percent of the annual health care expenditure in the United States. That's more than $120 billion dollars a year that is taken out of the U.S. health system, and away from necessary medical services.

Since 1993, fighting fraud and abuse in the health care industry has been one of the top priorities of the U.S. Department of Justice. At Capital BlueCross, we maintain a staff of Special Investigators who work with other health care carriers and law enforcement agencies to detect, investigate and prosecute persons responsible for committing health care fraud and abuse.

Report Suspected Fraud

How do perpetrators commit health care fraud?

Health care fraud schemes are diverse and vary in complexity.

Examples of fraud by Providers include:

  • Billing for services not actually rendered
  • Billing for services not medically necessary
  • Billing for a more costly service than was actually performed
  • Waiving patient copays and deductibles and overbilling the insurance carrier
  • Accepting kickbacks for patient referrals

Examples of fraud by Patients include:

  • Filing claims for services not provided
  • Forging receipts or altering information on actual receipts
  • Encouraging a health care provider to inflate or misrepresent the services provided
  • Allowing others to use their health insurance card

How you can protect your health care dollars

You can help identify potential fraudulent claims by doing the following:

  • Check your EOBs (Explanation of Benefits) for accuracy:
    • Dates of service
    • Services rendered
    • Charge amount
  • Use discretion when providing your health insurance information (contractholder ID number). Beware of offers for free health care services that ask for your insurance policy number. Guard that number as you would your credit card number.
  • Sign one claim form per visit.
  • Date your claim form. This will make it easier for you to match bills with services reported on the EOB.