About Health Care Fraud & Abuse
Blue Cross Blue Shield of Arizona has a special investigations unit dedicated to investigating referrals and tips from anyone suspecting fraud. Health care fraud continues to be an expensive problem and a nuisance to the public. The National Health Care Anti-Fraud Association (NHCAA) estimated that in calendar-year 2000, at least 3 percent ($39 billion) of the nation's annual health care outlay was lost to outright fraud. Everyone is ultimately affected through higher health insurance premiums, higher co-pays and fewer benefits.
Generally, fraud is an intentional misrepresentation that could result in some unauthorized benefit.
Abuse generally includes incidents or practices that are inconsistent with accepted sound medical practices, directly or indirectly resulting in unnecessary costs, improper payment, or payment for services that fail to meet professionally recognized standards of care or are medically unnecessary.
Common Examples of Health Care Fraud
Provider
- Billing for services not rendered: using valid patient information to make up entire claims or padding claims with charges for services that did not take place.
- Upcoding: billing for more expensive services than were actually provided, that is, falsely billing for higher priced treatment, which often requires "inflation" of the seriousness of a patient's condition.
- Providing unnecessary care: includes unneeded tests, surgeries and other services.
- Misrepresenting services: performing uncovered services but billing insurance companies for different services that are covered.
- Pretending to be health care professionals: delivering health care services without a license to do so.
- Using another provider's ID number to receive payment.
Member
- Doctor shopping: bouncing from one doctor to another in order to obtain multiple prescriptions, often for a controlled substance.
- Including misleading information on, or omitting information from, an application for health coverage: intentionally giving incorrect information to receive benefits.
- Adding an ineligible person to a contract: misrepresenting a relationship to a contract holder.
- Using ID cards that belong to someone else: using another person's insurance ID card to receive benefits.