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, Blue KC is part of a Blues Plans network and nationwide campaign to share how physicians, healthcare providers and customers can help with healthcare fraud and detection.

What is Healthcare Fraud and Abuse?
Protect Yourself
Protecting Members
Financial Impact
Who Commits Healthcare Fraud and Abuse?
Report Fraud and Abuse

What is Healthcare Fraud and Abuse?

Healthcare fraud takes place when a provider or consumer intentionally submits (or causes someone else to submit) false or misleading information for use in determining the amount of healthcare benefits payable. Healthcare abuse is similar to healthcare fraud, but where intent cannot be established.

Some examples of provider healthcare fraud and abuse are:

• Billing for services not actually performed.
• Falsifying a patient's diagnosis to justify tests, surgeries or procedures that aren't medically necessary.
• Misrepresenting procedures performed to obtain payment for non-covered services, such as cosmetic surgery.
• Upcoding – billing for a more expensive service than the one actually performed.
• Unbundling – billing separately for services that are typically billed together.
• Accepting kickbacks for patient referrals.
• Waiving patient co-pays or deductibles and over-billing the insurance carrier or benefit plan.
• Billing a patient more than the deductible, co-pay and coinsurance amounts for services.

Some examples of consumer healthcare fraud are:

• Visiting numerous doctors ("doctor shopping") to get multiple prescriptions for the same drug is illegal in most states, including Missouri and Kansas.
• Filing claims for services or medications not received.
• Forging or altering bills or receipts.
• Using someone else's coverage or insurance card.
• Allowing someone else to use your insurance card.

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Protecting Yourself

Medical Identity Theft is a fast-growing, but little known, crime in which a thief uses a person's name and social security or health insurance number to get medical treatment, or charge insurance companies for phony services. As many as 500,000 Americans have had their medical information stolen, and victims can be left with huge bills for services they never received, along with legal, medical and insurance-fraud issues that can take years to untangle. Even more, experts say that anyone with insurance is a potential victim of Medical Identity Theft. We encourage you to follow these general guidelines to safeguard yourself from medical identify theft and preventable medical errors, and improve the quality of care you receive.

• After care, review your statement to verify accuracy. Read your Explanation of Benefits.
• Ask your doctor to explain the reason for services.
• Report any discrepancies to Blue KC.
• Beware of "free" medical services, as illicit entities use this lure to obtain information.
• Safeguard your insurance card the same as you would your credit card.
• Report instances where co-payments or deductibles are waived.
• Don't give your insurance number to marketers or solicitors.
• Never sign a blank insurance form.
• Shred all old insurance cards and statements, or redact private information if you must keep them.
• You are entitled to a copy of your medical records. Review these records periodically for inaccuracies.

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Protecting Members

The Blue KC Special Investigations Unit (SIU) has been in continuous operation since 1986, and is part of the Audit Services Department. The unit is staffed by experienced investigators, who together monitor claims from a wide range of provider specialties. The SIU also utilizes specialized fraud and abuse detection technology to identify unusual billing activities, then works to address potential issues quickly and in compliance with corporate policies and procedures.

The SIU has a number of goals, including:

• To prevent and deter fraud and abuse through acts committed by providers, members, employees and any other Blue KC business constituents.
• To deter unnecessary medical services.
• To demonstrate the company's strong commitment to honest and responsible provider and corporate conduct.
• To facilitate compliance with state law, federal law, accreditation agency requirements, contractual requirements, and Blue Cross and Blue Shield Association requirements.
• To prevent processing of fraudulent or abusive claims.

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Financial Impact

In 2009 approximately $2.5 trillion was spent on healthcare in the United States. According to industry estimates, approximately 3 percent of that amount, or $75 billion, was lost to payment of fraudulent claims. Healthcare fraud has a wide impact, resulting in higher premiums for health insurance, higher copays and even higher taxes.

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Who Commits Healthcare Fraud and Abuse?

• Physicians and other practitioners;
• Pharmacists;
• Nurses;
• Individual patients;
• Laboratories;
• Billing Services;
• Hospitals;
• Medical equipment suppliers;
• Nursing homes;
• Employees of healthcare providers and insurers.

While the vast majority of healthcare professionals and others involved in the healthcare system are honest and ethical, healthcare fraud and abuse continue to be serious issues in America today.

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Report Fraud and Abuse

If you suspect that healthcare dollars are being paid improperly or as a result of false or misleading information provided to Blue KC, notify us by using the contact options listed below.

Complete a Healthcare Fraud and Abuse Complaint Form.

Email us at _SIU@BlueKC.com

Call our Hotline
816-395-3151 or 800-340-0119

Hotline for FEP Members
816-395-2870 or 800-337-8440

Hotline for Pharmacy Fraud and Abuse
816-395-3778

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Additional Resources:

• FBI
• Office of Inspector General Department of Health and Human Services
• Food and Drug Administration Department of Health and Human Services
• Office of Inspector General Department of Labor
• Missouri State Attorney General
• Kansas State Attorney General
• Missouri Department of Insurance
• Kansas Department of Insurance

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