Refocused Initiative on Fraud and Abuse


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Independence Blue Cross

The President and CEO of Independence Blue Cross (IBC) had a vision for self-contained, multidisciplinary Corporate and Financial Investigations Department (CFID) that could investigate and actively combat healthcare fraud and abuse. From 2000 to 2003, team members were brought in from a variety of disciplines. Former law enforcement agents, nurses, certified billing coders, auditors and employees with a background in the health insurance industry were hired. To make the CFID fully self-contained, a senior council attorney and senior clinical pharmacist were added to the team. The CFID was given the responsibility of auditing providers, which added to the fraud and abuse identification process and provider community sentinel effect.

Program Elements

  • New software to detect fraud and abuse was purchased and deployed over four years of medical and pharmacy claims, provider information and member benefits data. This software allowed the CFID analysts to actively mine the data to identify patterns and trends consistent with fraud or abuse.

  • A toll-free hotline was established for anonymous tip reporting.

  • Web sites were created; a proactive communication strategy to inform providers, members and employees about the Plan's activity was developed, along with enhanced coordination with law enforcement authorities.

  • The CFID's new configuration of expertise and resources allows the staff to work together as a team to more quickly identify and respond to potential fraud and abuse.

  • The CFID has also been able to influence public policy. The staff provided support on legislative issues facing the health insurance industry, notably helping to block recent legislation that would have restricted any healthcare plans' ability to recoup overpayments.

Program Results

  • In 2004, two investigations totaled over $1 million in court-ordered restitu­tion to IBC, and both investigations resulted in convictions and sentences for the perpetrators.

  • Also in 2004, 750 tips were received, 19 individuals were sentenced for healthcare crimes, and over $30 million in financial recoveries were made.

Contact

Ed Litchko, 215-241-2514, ed.litchko@IBX.com

 


 


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