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Report Fraud

BlueCross BlueShield of Tennessee is committed to protecting its members’ health and well being, as well as our corporate assets, by detecting, investigating and preventing wrongful acts committed against the corporation.

Financial losses incurred due to health care fraud, waste or abuse have a direct effect upon you. Payment of fraudulent claims increases health insurance premiums for everyone, and some forms of health care fraud and abuse, such as medically unnecessary X-rays, or using unqualified personnel to perform treatments, may also endanger your health, safety, and well being.

Who We Are & What We Do

Our Commitment to Fighting Fraud

To respond to the growing threat of health care fraud, BlueCross BlueShield of Tennessee established the Special Investigations Unit or SIU in 1983 to detect, prevent and pursue health care fraud and abuse.

Employees of the BlueCross BlueShield of Tennessee Special Investigations Unit (SIU) have backgrounds in law enforcement, investigations, legal, auditing, claims analysis and the medical professions.

How you can help fight fraud

Health care fraud costs you and other health care consumers millions of dollars each year. Help fight fraud, waste, and abuse in order to keep health care affordable:

  • Carefully review all charges listed on the Explanation of Benefits you receive from BlueCross. If we have paid for services you did not receive or paid an amount you do not think is right:

What is Fraud?

Health Care Fraud

Title 18 of the United States Code defines health care fraud as “knowingly and willfully executing, or attempting to execute a scheme or artifice to defraud any health care benefit program, or to obtain by means of false pretenses, representations, or promises, any of the money or property owned by, or under the custody of or control of, an health care benefit program.”

A working definition of fraud is simply the intentional misrepresentation, deception, or intentional act of deceit for the purpose of receiving payments and/or services that an individual or entity is not entitled to.

Elements of Health Care Fraud
  • Misrepresentation or concealment of a material fact on a health care claim
  • Knowledge that the misrepresentation is false
  • Intent to financially deprive or harm BlueCross and its customers
  • BlueCross, a victim, acting on the misrepresentation
  • Financial damage to BlueCross and its customers
What is the Cost of Health Care Fraud?

As estimated by the American Medical Association, National Health Care Anti-Fraud Association, Certified Fraud Examiners, and Department of Health and Human Services/Offices of Inspectors General, fraud represents between 3 and 10 percent of health care costs. In 2012, BlueCross BlueShield of Tennessee paid $10.5 billion in health care benefits. This means BlueCross could have potentially lost between $ 315,000,000 and $1,050,000,000.

What is Being Done about Health Care Fraud?
  • Legislative health care initiatives
  • Special Investigation Units (SIUs) established by private insurance companies
  • State-established Medicaid Fraud Control Units (MFCUs)
  • Health Care Task Forces established in the Eastern, Middle, and Western Districts of Tennessee, including the following agencies:
    • United States Attorney’s Office Federal Bureau of Investigation
    • United States Postal Inspector
    • Food and Drug Administration (FDA)
    • Office of Inspector General (OIG)
    • Tennessee Bureau of Investigation
    • BlueCross BlueShield of Tennessee’s SIU
  • National Health Care Anti-Fraud Association
  • Association of Certified Fraud Examiners

Types of Fraud

Common Types of Fraud

There are at least as many kinds of fraud as there are types of people who commit it, and fraud in the health care system is no exception. Here are ways a small percentage of people cause problems for consumers, other providers, health insurance companies – and anyone involved in health care:

Provider Fraud

  • Billing for services not provided
  • Billing of "free" services
  • Incorrect reporting of diagnoses or procedures to maximize payments
  • Waiver of deductible and/or copayment (unbundling, up-coding)
  • Overutilization of services
  • Kickbacks and bribery
  • Misrepresentation of dates or descriptions of services
  • Billing non-covered services as covered items
  • Eligible providers billing for services provided by ineligible providers

Subscriber Fraud

  • "Loans" an ID card to someone who is not entitled to use it
  • Enrolls someone not eligible for coverage on their BlueCross BlueShield of Tennessee contract
  • Alters amounts charged on claim forms or prescription receipts
  • Files fake claims

Non-Subscriber Fraud

  • Using a stolen ID card to receive medical services

Groups

  • Providing false employer group and/or group membership information

Employees

  • Files fake claims
  • Changes subscriber addresses to intercept payments
  • Providing false application data

Agents/Brokers

  • Falsifying group application data
  • Bribery and kickbacks

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Get answers to some of the most commonly asked questions about how the health care law impacts you.

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