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.
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:
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.
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.
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:
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