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Behind the scenes of the fight against health insurance fraud

Originally published by The Tennessean, November 2018

In 2016, a BlueCross member received an unsolicited prescription pain-relief cream in the mail.

It was prescribed by a doctor who she’d never seen and had not been part of any previously discussed treatment plan. The member was suspicious right away, so she called the BlueCross fraud hotline to report her concern.

That one tip ultimately led to the Department of Justice’s recent indictment of four individuals and seven companies who orchestrated an elaborate nationwide telemarketing scheme. It involved calling consumers to obtain their health insurance information, sending them pain creams and then billing their private insurers for continued use of the creams at exorbitant rates.

The case attracted national attention because it resulted in more than $174 million in fraudulent claims for hundreds of affected insurers, including about $2 million worth of fraudulent claims for BlueCross BlueShield of Tennessee in particular.

But this case is also an example of what we do every day to mitigate fraud, waste and abuse to help manage health care costs on behalf of our members.

The U.S. spends more than $2.9 trillion annually on health care. The National Health Care Anti-Fraud Association estimates more than $87 billion is lost every year to fraud, waste and abuse – about 3 percent of total payments.

Fraud is an intentional deception or misrepresentation made by a person who knows the deception could result in some unauthorized benefit or payment. Abusive activity pertains to practices by persons or entities that are inconsistent with sound fiscal, business or medical practices, and result in an unnecessary cost to health care insurers and programs.

As part of our culture of compliance, we hold ourselves just as accountable as we do our partners and network providers, looking to detect, investigate and prevent inefficiencies – or waste – within our own operations.

Outside of our walls, dedicated teams consisting of law enforcement and prosecutors work to detect and prosecute fraud and abuse.

The Special Investigations Unit at BlueCross is staffed by professionals with investigative backgrounds in the Tennessee Bureau of Investigation, the Environmental Protection Agency and the Secret Service, among others. These investigators identify fraud and recover the financial loss on behalf of our members.

For the pain-relief cream case in particular, our investigators were on the ground immediately after they established the legitimacy of the lead. They interviewed the doctor and discovered he was approving prescriptions for a fee. Once the depth of the scam became clear, we handed the investigation over to the authorities. In fact, we often work hand in hand with local, state and federal law enforcement, or district attorneys and attorneys general.

Health care is a massive, complex industry. That complexity lends itself to predatory actors  – be they opportunists, vendors, providers or consumers – who can take advantage of the vulnerable and uninformed among us. As the DOJ case demonstrates, massive fraud can occur through something as innocuous as a telemarketing call or pain-relief cream in your mailbox.

The nature of health care fraud is that investigators are often forced to be reactive rather than proactive.

Working more closely with data analytics, pharmacy and provider audit teams is crucial to identify bad actors gaming the system before fraud becomes an increased burden on consumers.

BlueCross is committed to protecting the health information, identities and financial security of our members.  We take the fight against fraud seriously because it puts all of those at risk.

You can help prevent fraud and abuse. If you are contacted about your health insurance information by an entity other than your provider or insurer, note their information, if possible, and call our Fraud unit at 1-888-343-4221.

About Julie Boerger, Vice President and Chief Compliance Officer

A photo of the authorJulie is responsible for all company compliance requirements and efforts to address health care fraud. She directs corporate efforts for the detection, investigation, prevention and prosecution of fraudulent acts for BlueCross and its subsidiaries and affiliates.

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