ST. PAUL, Minn., May 17 /PRNewswire/ — Through aggressive health care
fraud investigations and coordination among other states’ Blue Cross plans,
the Blue Cross Special Investigations Unit (SIU) stopped payment on more than
$3 million of suspect claims last year, reducing the impact of fraud on
premiums in Minnesota.
By comparison, Blue Cross stopped $8.7 million in claims in 2003, most of
which was due to the rent-a-patient scams now being investigated and
prosecuted in Southern California. “We saved millions of dollars of our members’ premium dollars, because we
were able to identify the scam early and stop payment on fraudulent claims,”
said Dave Bohnenstingel, SIU manager. “In fact, Blue Cross and Blue Shield of
Minnesota was integral in bringing the scam to light and the perpetrators to
justice,” he added. Bohnenstingel credited the drop in suspect claims in 2004 to the fact that
the rent-a-patient scam is now essentially defunct. In the spring of 2004,
the FBI raided several suspected clinics as part of its investigation of
150 clinics, eventually bringing federal charges against several of the
individuals involved.
In this scam, marketers recruited low income or minority patients, paying
them several hundred dollars and often transporting them to clinics solely for
unnecessary diagnostic tests or surgery. The clinics then billed the
insurance company an inflated amount for the procedures. The investigations
continue, but the fraudulent activity seems to have subsided. “Our experience has been that the overwhelming majority of providers and consumers act ethically and responsibly in submitting their health care bills;
however, there are exceptions who are trying to make money illegally at the
expense of payers,” Bohnenstingel said. “Unfortunately, those fraud losses
must be borne by our customers in the form of higher premiums.” Using sophisticated computer software, communication with Blues plans throughout the country, analysis of large claims, and tips to their fraud hot
line, Blue Cross’ SIU looks for irrgularities or other “red flags” in claims submitted by providers or members.
Blue Cross and Blue Shield of Minnesota has more than two decades of experience in detection and prevention of health care fraud. As one of the pioneers of developing an anti-fraud program, Blue Cross formalized an
aggressive anti-fraud program more than 10 years ago.
Blue Cross works with purchasers, the National Health Care Anti Fraud Association and several law enforcement agencies to combat fraud. As the state’s largest health plan, Blue Cross also spearheaded the creation of a
workgroup with other Twin Cities’ health plans to share information regarding local scams.
The national Blue Cross and Blue Shield Association estimates that between 3 and 5 percent of the dollars spent on health care in the United States in a year is lost to fraud.
If a consumer or employer suspects fraud, they can call the Fraud Hot Line at 651-662-8363 or 1-800-382-2000, extension 28363.
Blue Cross and Blue Shield of Minnesota, with headquarters in the St. Paul suburb of Eagan, was chartered in 1933 as Minnesota’s first health plan and continues to carry out its charter mission today: to promote a wider, more
economical and timely availability of health services for the people of Minnesota. A not-for-profit, taxable organization, Blue Cross is the largest health plan based in Minnesota, covering 2.6 million members in Minnesota and nationally through its health plans or plans administered by its affiliated companies. Blue Cross and Blue Shield of Minnesota is an independent licensee of the Blue Cross and Blue Shield Association, headquartered in Chicago.
Sidebar: What you can do to prevent health insurance fraud:
— Report suspected fraud to the Blue Cross fraud and abuse hotline
(1-800-382-2000, ext. 28363) or your health plan.
— Consumers should be cautious of free medical exams, co-payment
waivers, or advertisements stating “covered by insurance.”
— Think of health care member ID cards as being as valuable as a credit
card. If lost or stolen, they could be used to gain access to drugs
and services that may appear on your medical history.
— Closely examine “Explanation of Benefits” or EOBs from your health
insurer to ensure you received the service and the service billed was
the service you received. Call your health plan if there is a
discrepancy.
— Blue Cross offers educational materials and onsite training for
employers to share with employees about fraud.
SOURCE Blue Cross and Blue Shield of Minnesota