The purpose of this information is to increase your awareness of healthcare fraud, and to ask for your cooperation in reporting suspicious incidents to Blue Shield of California. It is important that everyone be aware of possible fraud and abuse, and report the incident as quickly as possible.
Whether it is an organized effort by a provider, member, or any other individual to deliberately cheat, or a healthcare provider who occasionally bends the rules to serve the perceived needs of a patient, healthcare fraud is a serious and growing problem. It exploits patients and robs them of services and resources critical to their well being.
By definition, fraud means that someone is trying to obtain something of value by intentionally deceiving, misrepresenting, or concealing. There are at least as many kinds of fraud as there are types of people who commit it, and fraud in the health care system is no exception. Here are a few examples of common types of healthcare fraud:
- Provider Fraud
- Billing for services not provided
- Billing of "free" services
- Incorrect reporting of diagnoses or procedures to maximize payments
- Waiver of deductible and/or copayment (unbundling, up-coding)
- Misrepresentation of dates or descriptions of services
- Billing non-covered services as covered items
- Subscriber Fraud
- "Loans" an ID card to someone
- Alters amounts charged on claim forms or prescription receipts
- Files false claims
- Non-Subscriber Fraud
- Using a stolen ID card to receive medical services
Healthcare fraud costs the United States approximately $60 billion annually. In 1989, Blue Shield established the Special Investigations Unit to centralize the company's efforts to combat this criminal activity. The investigators work to deter and prevent health care fraud and abuse, saving Blue Shield approximately $6 million a year.
Cooperation with anti-fraud efforts in the industry, as well as Federal, State, regulatory agencies, and local authorities is a crucial part of the department's activities. Criminal activities are referred to the appropriate government agency as quickly as possible.