Q1: My insurance card was stolen. Should I report it to BlueCross BlueShield of Tennessee (BCBST)?
A1: Yes, if your card is stolen you should contact BCBST immediately to prevent payment of services rendered to unauthorized persons using the card. You are the most powerful weapon in the fight against health care fraud.
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Q2: I received an Explanation of Benefits for services I didn't receive. Is this fraud?
A2: Possibly. Billing for services not rendered is one of the most common types of health care fraud committed by providers. However, there are instances when a provider mistakenly submits a claim with an incorrect insurance identification number causing payment to be issued under the wrong patient. Always report erroneous charges to BCBST. Our Special Investigations Unit will thoroughly research the charges and determine whether fraud has been committed or a simple billing error has occurred.
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Q3: I receive diabetic/Durable Medical Equipment supplies in the mail monthly, even when I don't need them. I've notified the provider, but they continue to send them. Is this fraud?
A3: Intentionally billing for services which are not medically necessary is considered fraud . Often providers flood BCBST patients with alcohol swabs, sterile pads and various other supplies that are unwanted and unneeded. Many patients complain that their closets are running over with these supplies, but the provider ignores their requests to decrease the number of supplies being shipped. This situation should immediately be reported to the SIU of BCBST.
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Q4: My sister is sick and needs to go to the doctor, but she doesn't have insurance. No harm will be done if I let her use my BCBST card for medical services, right?
A4: Wrong! Allowing unauthorized persons to use your BCBST insurance card for medical services could result in criminal prosecution for you and the person using your card.
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Q5: My doctor billed BCBST for an office visit when all I had to do was pick up a prescription. I never saw the doctor. Can he charge for this?
A5: No, this would be considered billing for services not provided and should be reported to BCBST immediately.
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Q6: I received a check from BCBST by mistake. Should I cash the check and spend the money or call BCBST to report it?
A6: You should notify BCBST and return the check immediately. Knowingly accepting an erroneous payment could result in criminal prosecution or a civil suit. If it is proven that you intentionally damaged BCBST financially, you could end up in jail and the risk is not worth it.
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Q7: I suspect that my physician may be billing fraudulent charges, but I can't be sure. If I call you and you investigate and confirm that no fraud is being committed, will my provider know I reported him and will he treat me differently?
A7: You should never be afraid to report your physician for suspicions of fraudulent billing or inappropriate behavior. You are not required to identify yourself when reporting suspected fraud, but should you choose to do so, you may ask to remain anonymous. We take every complaint seriously and are committed to protecting our customer's confidentiality. Remember, if the provider is filing fraudulent charges under your insurance coverage, then he or she most likely is filing false charges under someone else's.
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Q8: What are the most common types of fraud that BCBST encounters from provider?
A8: The most common types of fraud which we encounter on a routine basis are intentional misrepresentations, which include:

• Billing for services not given
• Double billing
• Confused billing (mixing multiple dates of service on the same claim)
• Inflated billing
• Unbundling (filing separate charges for each component of one medical procedure)
• Up-coding (billing a higher level of service than was actually performed)
• Generic drugs used in place of brand name drugs

Q9: What is the cost of health care fraud to BCBST?
A9: It is unknown what the actual cost is to BCBST, but if we experience the same percentage of loss due to fraud and abuse as the national average, 10 percent of billings are possibly false. This translates to millions of dollars in losses each year.
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Q10: What is being done about health care fraud?
A10: Private insurance companies are establishing Special Investigative Units. The Federal Bureau of Investigation is dedicating resources to health care fraud. Health Care Task Forces have been established, which include Assistant US Attorney Generals, the FBI, SIU’s, Postal Inspectors, the Federal Drug Administration, the Office of Inspector General and other local law enforcement agencies.
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Q11: What should you do if you find that your prescription pads have been stolen?
A11: Notify the police of the theft.
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Q12: If a physician believes that one of his or her employees is diverting BCBST claims payment checks or falsifying insurance claims in order to receive stolen monies, what should the physician do?
A12: Conduct an independent audit of accounts receivable and accounts payable. Prohibit the ability of any one person to misappropriate accounts receivable. Notify BCBST of any false payments that occurred
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Q13: I am a health care provider. What should I do if another provider offers to refer patients to me for certain financial incentives?
A13: You should decline the offer, notify the United States Attorney General and cooperate with federal investigators
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