Help Us Fight Health Care Fraud, Waste and Abuse

What Is Health Care Fraud, Waste and Abuse?

Fraud is knowingly and willfully executing, or attempting to execute, a scheme or artifice to defraud any healthcare benefit program or to obtain (by means of false or fraudulent pretenses, representations, or promises) any of the money or property owned by, or under the custody or control of, any healthcare benefit program.

Waste is the overutilization of services, or other practices that, directly or indirectly, result in unnecessary costs to the Medicare program. Waste is generally not considered to be caused by criminally negligent actions, but rather the misuse of resources.

Abuse includes actions that may, directly or indirectly, result in: unnecessary costs to the Medicare Program, improper payment, payment for services that fail to meet professionally recognized standards of care, or services that are medically unnecessary. Abuse involves payment for items or services when there is no legal entitlement to that payment, and the provider has not knowingly and/or intentionally misrepresented facts to obtain payment. Abuse cannot be differentiated categorically from fraud, because the distinction between “fraud” and “abuse” depends on specific facts and circumstances, intent and prior knowledge, and available evidence, among other factors.

How Does Fraud, Waste and Abuse Affect You?

Fraud, waste, and abuse affects you by paying higher co-payments and premiums. This means more money out of your pocket. Fraud can also impact the quality of care you receive and falsify your medical history. Fraud can also deprive you of some of your health benefits.

Studies show that over 30 billion dollars a year is lost to health care fraud in the United States. In order to control costs, insurance companies have found it necessary to investigate fraud for the benefit of its members.

Who Commits Fraud?

Fraud can be committed by members, providers and employers.

Examples of Member Fraud

Using someone else’s ID card or loaning your ID card to someone not entitled to use it. Providing false statements on an enrollment application such as spouse or dependent information to obtain coverage or concealing information about past medical history/preexisting conditions.

Failing to report other insurance or to disclose claims that were a result of a work related injury.

Examples of Provider Fraud

  • Billing for services that were not rendered.
  • Providing services that are not medically necessary for the purpose of maximizing reimbursement.
  • “Upcoding”-billing for a more costly service than was actually provided.
  • “Unbundling”-billing each step of a test or procedure as if it were separate instead of billing the test or procedure as a whole.
  • Submitting claims with false diagnoses to justify tests, surgeries or other procedures that are not medically necessary.
  • Waiving member co-pays or deductibles.
  • Accepting kickbacks for member referrals.

How We Are Fighting Fraud

Blue Cross and Blue Shield of Kansas City (Blue KC) fights fraud and helps protect the monies our members spend on health care through a dedicated department called the Special Investigations Unit (SIU). The SIU uses the latest fraud-detection software, fraud hot lines, audits, data analysis and other tools to identify and investigate improper, deceptive and fraudulent billing.


Identify

Blue Cross and Blue Shield of Kansas City (Blue KC) employees are trained in how to identify fraud and abuse and how to refer these to the SIU.

Investigate

SIU staff perform in-house and on-site audits. These audits verify medical necessity and appropriateness of services, proper billing, eligibility for coverage and more.

Prevent

Claim management tools assist with the identification of inconsistent and illogical relationships among claims data. State of the art data mining tools are used to identify providers and members who may be involved in fraud.

Report

Our toll-free hotline (1-844-227-1790) - makes it easy for anyone to report suspected fraud and abuse. This number is available 24 hours a day 7 days a week. You may leave your name and number or choose to remain anonymous.

Onlinewww.bcbskc.ethicspoint.com

In writing – Blue Cross and Blue Shield of Kansas City (Blue KC) ATTN: SIU Dept. 2301 Main Street, Kansas City, MO 64108

Via emailmacompliance@bluekc.com

All reports are investigated and involve the appropriate federal and state agencies when necessary.

You Can Help Fight Fraud, Too!

One way you can help fight fraud is to look over your Explanations of Benefits (EOBs) when you receive it in the mail. The EOB is your notification that Blue Medicare Advantage received a bill for services performed under your benefit plan. Check to be sure you received the services listed. Are the dates correct? Are there charges that seem wrong to you? Report any suspicious activity or questionable services to our toll-free hot line: 1-844-227-1790 (TTY: 711). This number is available 24 hours a day 7 days a week. All calls and information received are handled confidentially.

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