; Blue Cross And Blue Shield Companies Recognized For Anti-Fraud Efforts
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Press Release

Blue Cross And Blue Shield Companies Recognized For Anti-Fraud Efforts

May 26, 2011

WASHINGTON – Prevention, detection and investigation of healthcare fraud and abuse is more critical than ever to safeguard consumers’ healthcare dollars.  The National Health Care Anti-Fraud Association estimates that $75 billion to $250 billion is lost to healthcare fraud annually.

Anti-fraud efforts have long been a robust component of the Blue Cross and Blue Shield companies’ commitment to improving the accessibility and affordability of healthcare services for its members.  In recognition of their successful anti-fraud programs and investigations, the Blue Cross and Blue Shield Association (BCBSA) presented its 2011 BlueWorks® Anti-Fraud awards to two Blue Cross and Blue Shield companies. 

Blue Cross Blue Shield of Michigan was recognized for an investigation of a provider who charged his patients inflated amounts for his services and then filed civil actions against patients when they challenged the claims submissions or could not pay. 

Blue Cross and Blue Shield of Georgia was recognized for a criminal investigation that revealed excessive billing and protracted treatment times from a string of chiropractic offices.

“Blue Cross and Blue Shield companies are having tremendous success as they work with state and federal law enforcement to combat healthcare fraud and abuse,” said Scott P. Serota, BCBSA president and CEO.  “Our efforts are helping to keep consumers safe and guard against the waste of healthcare dollars.”

In partnership with the Harvard Medical School Department of Health Care Policy, BCBSA, recognizes Blue Cross and Blue Shield companies’, through its BlueWorks program for anti-fraud investigations that have identified and promoted best practices in the areas of investigation and prosecution, fraud risk identification, mitigation, and prevention.  This year’s winning programs are summarized below:

Blue Cross Blue Shield of Michigan
Non-Criminal Investigation:  Participating Provider Billing Fraud

An extensive investigation determined a provider was in violation of his Participating Provider Agreement and was not accepting approved payments along with proper co-pays and deductibles for his Blue Cross Blue Shield of Michigan (BCBSM) patients.  Instead he charged his patients inflated amounts for his services.  When his patients did not make timely payments for the inflated charges or challenged his claim submissions, the provider would file civil actions against them.  BCBSM Corporate and Financial Investigations Investigators not only investigated all aspects of this case, but supported BCBSM members in their defense against the provider’s numerous frivolous lawsuits.

Blue Cross and Blue Shield of Georgia
Criminal Investigation:  Chiropractic Billing Scheme

Data analysis from a string of chiropractic offices revealed excessive billing, especially for protracted treatment times for members and their families for a particular employer group.  The Blue Cross and Blue Shield of Georgia (BCBSGA) Special Investigative Unit (SIU) began a large scale investigation which included undercover activity in order to determine how the billing differed from the treatment provided.  The probe resulted in successful discovery of evidence and intent to defraud.  Kickback arrangements were clearly established and the scheme resulted in actual harm to members through the depletion of their benefits.  Four million dollars in restitution was ordered by the court.

“These investigations and programs illustrate the effects of teamwork and investigative excellence in reducing fraud and making healthcare safer for our members,” said Byron Hollis, managing director of BCBSA’s National Anti-Fraud Department.  “We are protecting consumers and saving healthcare dollars by developing preventive programs and working in partnership with consumers, law enforcement, and authorities to investigate potential fraud cases.”

Blue Cross and Blue Shield members can report suspected fraud through a national hotline number, 1.877.327.BLUE, and website (www.bcbs.com/blueresources/anti-fraud/report-fraud.html).

 About Blue Cross and Blue Shield Association

The Blue Cross and Blue Shield Association is a national federation of 37 independent, community-based and locally-operated Blue Cross and Blue Shield companies that collectively provide healthcare coverage for more than 105 million members – one-in-three Americans.  For more information on the Blue Cross and Blue Shield Association and its member companies, please visit bcbs.com. We encourage you to connect with us on Facebook, check out our videos on YouTube, follow us on Twitter and check out The BCBS Blog, for up-to-date information about BCBSA.