Health Care Fraud
Experts believe up to 10% of all health care costs are fraud. When those costs add up, they can hurt members like you. Because if we pay for services that members don’t need, or if we pay for services for people who aren’t members, that could bump up what you pay for health insurance. Plus, getting tests you don’t need and getting treatments from people that don’t have the right training could hurt you even more. That’s why we look out for you and protect you by investigating, finding and stopping fraud.
What is health care fraud?
People who don’t tell the truth to get health care or payments they don’t deserve are committing health care fraud. And it isn’t just unfair – it’s also a crime.
Doctors can commit fraud by:
- Charging for care you didn’t receive, asking to get paid for “free” services or taking bribes or money for care, then not charging you.
- Not telling the truth about the care they gave you to get more money, lying about dates or services they offer, and charging for care from a doctor who isn’t eligible.
Members can commit fraud by:
- Giving their member ID card to someone who isn’t covered by the health plan, changing prices on claims and receipts for medical care and medicines, and filing fake claims or adding someone to a BlueCare Tennessee plan who doesn’t qualify for it.
People who aren’t members can commit fraud by:
- Using a stolen member ID card to get medical care.
Agents and brokers can commit fraud by:
- Lying about the information on a person or company’s application, and taking bribes or money for services.
Employers can commit fraud by:
- Using fake information about its employees on an application.
How do we fight fraud?
Our Special Investigations Unit (SIU) is made up of professionals and investigators who used to work in law enforcement. They’re very good at spotting lies on claims, and they protect you by investigating fraud.
SIU works with members, BlueCross employees, different health plans and other people to find and stop fraud. Sometimes they even work with local, state and federal law enforcement officers to bring down those who break the law and commit fraud.
Who else fights fraud?
Many groups and organizations fight fraud, including the Health Care Task Forces in East, Middle and West Tennessee, United States Postal Inspector, Food and Drug Administration (FDA), Office of Inspector General, Tennessee Division of Investigation, National Health Care Anti-Fraud Association, and Association of Certified Fraud Examiners.
Each state has a Medicaid Fraud Control Unit. Many insurance companies have dedicated employees to protect people against fraud, too. Lawmakers also help by passing laws to fight fraud.
How can you help?
You can do your part in fighting fraud. Your tips can help us find and stop fraud. Here are a few things you can do to help:
- Look over the charges on the Explanation of Benefits we send you. Let us know if we paid for tests or treatments you didn’t get or paid a bill that didn’t look right.
- Keep your ID and member ID card safe so they don’t get stolen and used by someone else. It’s also a good idea to destroy your old ID cards.
- Never give your Social Security number over the phone to anyone you don’t know
If you notice something that could be health care fraud, we’d appreciate your help. You can report fraud online here. Or you can call our hotline at 1-888-343-4221.