; Horizon Blue Cross Blue Shield Of New Jersey’s Anti-Fraud Efforts Yield Savings And Recoveries To Members, Health System
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Press Release

Horizon Blue Cross Blue Shield Of New Jersey’s Anti-Fraud Efforts Yield Savings And Recoveries To Members, Health System

$16.1 million in collections and recoveries through August; $26 million achieved in 2012

September 30, 2013

NEWARK – Horizon Blue Cross Blue Shield of New Jersey (Horizon BCBSNJ) announced today that its efforts to combat health insurance fraud resulted in $16.5 million in savings - identified as a combination of monies recovered and losses avoided – through the first eight months of 2013. The anti-fraud efforts, led by Horizon’s Special Investigations Unit (SIU), also yielded $26 million in 2012. A total of 776 new cases were opened during the calendar year.

“Healthcare fraud takes many forms and Horizon deploys sophisticated tools and strategies to detect and prevent it,” said Douglas Falduto, Vice President, Administration and Chief Security Officer for Horizon BCBSNJ.  Falduto said that data mining and special software tools, joint investigations with law enforcement agencies and tips from employees, members and health care providers all contribute to Horizon BCBSNJ’s success in rooting out fraud. “While fraudulent activity is a hidden problem, Horizon is committed to uncovering and fighting it to ensure that healthcare dollars are used appropriately and honestly.”

Over the last five years alone -- from 2008 through August 31 of this year -- the Special Investigations Unit has generated $148 million in combined savings and recoveries for Horizon BCBSNJ members.

Falduto said fraud and abuse can involve both health care providers and health care consumers. Common examples include:

Providers:

  • Billing for a fraudulent diagnosis
  • Billing for services not rendered
  • Billing for services not furnished as billed, also known as “upcoding”
  • Inappropriate physician/ancillary provider relationships resulting in kickbacks

Consumers:

  • Filing a false claim
  • Using a false ID number
  • Misrepresenting a dependent as eligible for policy coverage

How much is lost to healthcare fraud each year? According to National Health Care Anti-Fraud Association estimates, three to ten percent of what Americans spend annually on health care is lost to fraud — between $30 billion and $140 billion a year.

Approximately 60 percent of the fraud cases investigated by Horizon BCBSNJ are detected by Horizon BCBSNJ employees or by Horizon members who contact the company.

“Horizon relies on the eyes and ears of our members to help us identify and investigate fraud,” Falduto said. “We encourage members to call us if they detect suspicious activity on their EOB (Explanation of Benefit) forms or during their provider visits.”

Horizon BCBSNJ’s Anti-Fraud hotline for confidentially reporting tips is 1-800-624- 2048. In 2012 alone, the hotline received 2,349 calls.

About Horizon Blue Cross Blue Shield of New Jersey
Horizon Blue Cross Blue Shield of New Jersey, the state’s oldest and largest health insurer, is a tax-paying, not-for-profit health services corporation, providing a wide array of medical, dental, and prescription insurance products and services.  Horizon BCBSNJ is an independent licensee of the Blue Cross and Blue Shield Association, serving 3.7 million members with headquarters in Newark and offices in Wall, Mt. Laurel, and West Trenton.  Learn more at www.HorizonBlue.com

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.