We protect you by preventing, finding and investigating health care fraud.
Health care fraud affects you in several ways. Your health care premiums could go up if we pay for services members do not need. Your premiums may go up if we pay for services for non-members, as well.
Fraud can hurt you in other ways. Medical tests you do not need and treatments from unqualified people put your health and safety at risk.
BlueCross BlueShield of Tennessee formed its Special Investigations Unit (SIU) in 1983. The SIU is the investigative arm of the BCBST Enterprise. It services all product lines, including but not limited to: BlueCare Tennessee, Medicare Advantage, State of Tennessee, and the Federal Employee program. The unit is made up of former state and federal law enforcement officers as well as a nurse coder. These highly-trained professionals work with a number of internal and external partners to prevent, detect, and investigate health care fraud.
You can help us find fraud. Read over charges listed on the Explanation of Benefits we send you. Let us know if we paid for tests or treatments you did not get or paid an amount you think is not right.
Visit SIU to report anything you think might be fraud
Or Call 1-888-343-4221
Health care fraud is:
Sending claims information that is not true or is misleading Knowing the information is not true Knowing the claim could cost BlueCare Tennessee and our members money .
Experts say between three and 10 percent of health care costs are fraud. Those numbers add up quickly.
Many groups and organizations fight fraud. They include:
Health Care Task Forces in East, Middle and West Tennessee United States Postal Inspector, Food and Drug Administration (FDA) and Office of Inspector General
Tennessee Bureau 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 help by passing laws to fight fraud.
Health care providers can commit fraud by:
Billing for services you did not receive. Billing for “free” services or overusing services. Taking bribes or money for providing services (kickbacks) and waiving your deductible or copayment.
Not correctly reporting services to get more money, not being honest about dates or services they provide. Billing for care from a provider who is not eligible.
Members can commit fraud by:
Loaning a member ID card to someone who is not covered by the health plan. Changing prices on claims and receipts for medical care and medicines. Filing fake claims or adding someone to a BlueCare Tennessee plan who is not eligible for coverage.
People who are not members can commit fraud by: Using a stolen member ID card to get medical care.
Agents and brokers can commit fraud by:
Using false information in a person or company’s application. Taking bribes or money for providing services (kickbacks).
Employers can commit fraud by: Using fake information about its employees on an application.