Fraud FAQs
1) What is the role of the Blue Cross and Blue Shield Association’s (BCBSA) National Anti-Fraud Department (NAFD)?
The NAFD:
- Provides healthcare fraud management direction and support to the anti-fraud units employed by the 39 independent BCBS Plans.
- Coordinates the BCBSA National Anti Fraud Strike Force multi-jurisdictional and foreign claims related activities; and
- Provides services to the Blue Plans’ anti-fraud units in detecting, preventing, and investigating healthcare fraud, and recovering improper payments.
- Protect the FEP program from fraud, waste and abuse through oversight of Plan investigative activity related to the FEP program as well as conducting investigation that compliment to work done by the local Plan.
2) How many people are employed by the BCBSA and the 39 independent BCBS Plans to combat healthcare fraud?
In 2008, more than 500 employees were dedicated to BCBSA and the BCBS Plans' anti-fraud efforts across the nation.
3) What is the primary focus of the BCBSA's anti-fraud efforts?
The NAFD works with the BCBS Plans, the healthcare community, consumers, and others to prevent improper payments. by coordinating investigative activity by multiple plans, providing additional investigative support as needed and providing a mechanism whereby the Plans Anti Fraud Investigators can network and exchange intelligence information.
4) What does the NAFD do when it receives a healthcare fraud complaint from a citizen or member?
The NAFD evaluates the complaint, routes it to the responsible BCBS Plan anti-fraud unit, and monitors the activity to insure an appropriate resolution. It also provides investigative support services and advice.
5) Does the BCBSA's NAFD have a national strategy to confront healthcare fraud?
The NAFD has developed a national strategy that includes:
6) How important is healthcare fraud at the BCBSA?
The NAFD reports directly to the BCBSA Chief Auditor and Compliance Officer, who reports directly to the BCBSA CEO and Audit committee. This illustrates BCBSA's commitment to eradicating healthcare fraud.
7) Are my visits to a foreign provider, while traveling internationally, scrutinized for fraud?
Yes. If you are a member and receive medical care in a foreign country, the claim submitted on your behalf is reviewed for fraudulent activity before payment is authorized.
8) What happens to my fraud complaint?
The complaint is evaluated and research is conducted to determine if evidence supports the details of the complaint. Appropriate efforts to recover improper payments are made. If evidence of criminal wrongdoing is uncovered, the proper authorities are notified. In certain instances, you may be asked to testify to help authorities enforce the law.
9) Are the detection, prevention, and prosecution of healthcare fraud the sole responsibility of the BCBS Plan anti-fraud units?
When BCBS Plan employees detect healthcare fraud, the work is delivered to the proper authorities whose responsibility it is to enforce the law. Typically, government or private attorneys join with judges and juries to prosecute wrongdoing.
10) How do individual BCBS Plans detect healthcare fraud?
The Blue Plans' anti-fraud units employ:
- Consumer education;
- Comprehensive examination of claim submissions, post payment;
- Review of claim histories; gathering evidence;
- Testimony, media outreach, participation in task forces and professional organizations;
- Liaison with law enforcement authorities; and
- Use of the internet and compliance measurement methods.
11) Is healthcare fraud considered a "federal case"?
Healthcare fraud can be prosecuted in local and state courts for theft, deceptive business practices, tax avoidance, etc. There is a specific federal statute for healthcare fraud. The NAFD works with the FBI, the Office of Inspector General for the Department of Health and Human Services, and others, to prosecute through the federal system.
