Blue Cross And Blue Shield Companies Receive BlueWorks® Awards For Anti-Fraud Efforts
May 19, 2008
SCOTTSDALE, AZ - Five Blue Cross and Blue Shield companies were recognized today as recipients of the annual BlueWorks® Anti-fraud Awards for their efforts in fighting healthcare fraud. Blue Cross & Blue Shield of Mississippi, Capital BlueCross, BlueCross BlueShield of Western New York, BlueShield of Northeastern New York and Regence BlueCross BlueShield of Utah were honored during the Blue Cross and Blue Shield Association's (BCBSA) 2008 National Internal Audit and Anti-Fraud Conference in Scottsdale, AZ.
The BlueWorks program represents collaboration between BCBSA and Harvard Medical School's Department of Health Care Policy to recognize innovative programs by Blue Cross and Blue Shield companies. For the past four years, the BlueWorks program has recognized Blue companies for their exemplary anti-fraud activities and honored successful programs that promote knowledge-based solutions and empower consumers and providers.
"Blue Cross and Blue Shield companies are in the forefront of the fight against healthcare fraud. They are committed to protecting consumers and ensuring healthcare quality, value and access," said Scott P. Serota, BCBSA president and CEO. "Their hard work is illustrated by these BlueWorks award-winning investigations and programs which show how positive results are achieved through collaboration with providers and consumers. These award winners also serve as model programs that can be replicated by other Blue companies and other health insurers."
Three researchers from Harvard's Department of Health Care Policy were joined by three nationally recognized anti-fraud experts in the assessment of Blue companies' anti-fraud efforts in two categories – excellence in investigations and excellence in programs.
Anti-fraud Investigation Awards
The two awards for best anti-fraud investigations were given to Blue Cross & Blue Shield of Mississippi and Capital BlueCross in Pennsylvania.
Blue Cross & Blue Shield of Mississippi
Blue Cross & Blue Shield of Mississippi's Special Investigation Unit (SIU) investigated claims submitted by a therapist who was providing tutoring services for Children's Health Insurance Program-eligible school children while charging a rate intended for individual psychotherapy. This investigation is currently in the prosecution stage, and more than $840,000 was allegedly overpaid.
This investigation provides other Blue companies with a replicable roadmap by promoting an on-site approach when non-covered services billing is suspected and the integrity of medical records could be compromised.
The judges cited the rapid turnaround from discovery to an on-site audit and prosecution. They commended the prompt way the initial report was taken from the member relations department to a compliance group, demonstrating a company-wide awareness of fraud and abuse. The judges also noted how investigators manually uncovered the creative billing scheme since it was not detectable by software or other algorithms.
Capital BlueCross
Capital BlueCross' Special Investigations (SI) conducted an investigation to determine if their Plan's contracted home infusion therapy providers were accurately reporting pharmaceuticals and related services. This investigation's objectives were to audit infusion providers, identify and collect overpayments, educate and enhance provider relationships and improve internal processes. This collaborative effort involved numerous company departments, including SI, actuarial services and several provider departments.
Savings from provider refunds in 2006-07 and projected savings from corrected billing of services total more than $2.6 million. With implementation of the new reimbursement system, Capital BlueCross anticipates saving an additional $2.3 million annually.
The judges commended this investigation citing its cooperative approach with providers and efforts at creating a proactive educational opportunity with vendors.
Anti-fraud Program Awards
The two awards for best anti-fraud programs went to Regence BlueCross BlueShield of Utah, BlueCross BlueShield of Western New York and BlueShield of Northeastern New York.
Regence BlueCross BlueShield of Utah
Through a comprehensive program conducted in collaboration with the Utah Department of Insurance, Regence BlueCross BlueShield of Utah's SIU identified ineligible dependents and recovered dollars paid out for their care. Created in 2003, this program identified an actual savings in excess of $400,500 in recoveries and close to an additional $80,000 in identified but unrecoverable losses. The estimated savings from this project are more than $2 million.
The judges noted the program's promotion of fair play and the fact there were actual recoveries with the potential for projected savings in the future.
BlueCross BlueShield of Western New York and BlueShield of Northeastern New York
In 2006, the BlueCross BlueShield of Western New York and BlueShield of Northeastern New York's SIU conducted a pilot program to determine if erroneous charges by health systems using percentage-based methods of charging for high-cost cases were leading to inflated reimbursement claims. Initial findings indicated there were substantial charges for drugs and other items and services not appearing in medical records.
In 2007, this program was expanded to include all high-cost claims that met the criteria established during the pilot phase. Twenty-seven claims were reviewed, representing total charges of more than $4 million and net overcharges of nearly $900,000 and recoveries of more than $400,000.
The judges commended this program as proactively employing inter-department cooperation. They also noted its fair approach, since both potential undercharges and overcharges were reviewed.
The BlueWorks program, launched in October 2003, has recognized more than 50 Blue Cross and Blue Shield programs that are helping to keep quality healthcare affordable in communities across the country. For a complete list of BlueWorks winners, go to http://www.bcbs.com/blueworks.
The Blue Cross and Blue Shield Association is a national federation of 39 independent, community-based and locally operated Blue Cross and Blue Shield companies that collectively provide healthcare coverage for more than 100 million individuals - one-in-three Americans. For more information on the Blue Cross and Blue Shield Association and its member companies, please visit www.BCBS.com.
