Anti-Fraud and Financial Investigations
Last year, the FBI estimated that between 3% and 10% of all health care spending in the U.S. went towards fraudulent claims. Fraud has real effects on everyone in the health care system. For members, fraud increases the costs of benefits and reduces the quality of care they receive. For employers, fraud increases the cost of providing benefits and the overall cost of doing business. Fraud can often result in unsafe medical procedures and false medical records which can lead to devastating effects.
The Corporate and Financial Investigations Department (CFID) at Independence Blue Cross (IBC) continues to add value to our fight against health insurance fraud, waste, and abuse (FWA). CFID detects and investigates potential areas of FWA with the help of confidential information received from many stakeholders, including providers, members, employees, and members of the general public. In 2013 alone, CFID recovered $65.8 million in fraudulent, abusive, or wasteful claims paid. In the last five years, more than $325 million has been recovered by CFID in fraudulent, abusive, or wasteful claims.
How You Can Help
CFID owes much of its success to the members, providers, and other stakeholders who have been instrumental in reporting fraudulent activities. If you suspect health care fraud against Independence and/or you, we urge you to report it. All reports are confidential. You are not required to provide your name, address, or other identifying information.
Examples of Fraud
Fraud can be committed by, and affect, stakeholders across every area of the health care system. Health care fraud is a serious crime that affects everyone’s health care and is a costly reality that we cannot afford to overlook. Health care fraud is a federal criminal offense punishable by up to 20 years in federal prison.
Most Common Types of Fraud
- billing for services not provided
- billing for more expensive services than were actually preformed, commonly known as upcoding
- performing medically unnecessary services solely for the purpose of reimbursement
- billing non-covered services (e.g., cosmetic) as other covered services
- prescription fraud and pharmaceutical diversion to include Medicare Part D
- providing false information during enrollment
- accepting bribes or kickbacks for patient referrals
- routinely waiving co-payments and/or deductibles
- medical identity theft
Things to Look Out For
- Review your claims at ibxpress.com by selecting “View Claims” to ensure you have received all services billed under your name.
- Protect your health insurance card like you would a credit card.
- Never provide health plan identification number to someone you don’t know.
- Any free medical services being offered at community fairs or other events should never require you to provide your health plan identification number.
If you suspect health care fraud against Independence Blue Cross or any health insurance company, we urge you to report it. All reports are confidential. You are not required to provide your name, address, or other identifying information.
How to Report Fraud
Report fraud using any of the following three methods:
- Submit the Online Fraud and Abuse Tip Referral Form electronically.
- Call the confidential anti-fraud and corporate compliance hotline toll-free at 1-866-282-2707 (TTY/TDD 1-888-789-0429), 8:30 a.m. to 4:30 p.m. ET, Monday through Friday.
- Mail your report. Write a description of your complaint, enclose copies of any supporting documentation, and mail it to:
Independence Blue Cross
Corporate and Financial Investigations Department
1901 Market Street
Philadelphia, PA 19103
Reprinted with permission of the Blue Cross® and Blue Shield® Association