Health care fraud, waste and abuse (FWA) is not a victimless crime; it affects individuals and businesses alike.
The National Healthcare Anti-Fraud Association (NHCAA) estimates that 3-10% of the money spent on health care is lost to FWA, equating to an estimated $30-$140 billion in losses each year.
How FWA occurs
Health care FWA can be committed by medical providers, patients or anyone who intentionally deceives the health care system. Some examples of health care FWA include:
Provider FWA schemes
- Providing unnecessary procedures or excessive services
- Submitting claims for services not rendered
- Upcoding – using billing codes for procedures that are more costly than the treatment
- Misrepresenting services – billing for an uncovered service using a covered procedure code
Member FWA schemes
- Visiting multiple providers to obtain prescription medications
- Forging or altering bills or receipts
- Falsely adding dependents or misrepresenting address or re-employment information
- Misrepresenting claim information by adding false information when self-filing claims
The consequences of FWA
Health care FWA can raise insurance premiums, expose members to unnecessary medical procedures, and sometimes, reduced services.
Blue Cross and Blue Shield of Nebraska (BCBSNE) has a comprehensive fraud, waste and abuse program, which is led by the Special Investigations Unit (SIU) and Provider Audit department. The team is small but mighty, consisting of three investigators and two provider auditors who are responsible for detecting, investigating and ultimately ending instances of fraudulent, wasteful and abusive activity toward BCBSNE and its assets.
SIU in action
The BCBSNE SIU team diligently combats fraud by collaborating with internal departments, associations and law enforcement, as well as using Health Care Fraud Shield, a fraud analytics tool that helps identify FWA. The department also receives intensive, ongoing training in fraud detection to stay current with detection and prevention practices.
2020 SIU highlights
In the last year, BCBSNE’s SIU team has saved the company and its members approximately $2.5 million through the following actions:
- Savings (claim payment reductions that result from a pre-payment review): $345,012
- Recoveries (claim payment reductions that result from a post-payment review): $113,651
- Settlements (actual dollars recovered as part of a settlement agreement following a post-payment review): $264,000
- Prevented loss (the 12-month financial impact that results from actions taken or initiated by SIU related to an investigation): $349,145
- Projected savings (predicted 12-month financial impact that results from a policy or process change suggested by the SIU that is unrelated to an investigation): $1,476,817
“Every day we work to do the right thing by our customers, members and providers,” said Adrian Czapla, special investigations and provider audit manager. “We are dedicated to being proactive and vigilant when it comes to FWA, and I believe our commitment to this is evident based on the savings we incurred in 2020.”
If you ever have questions or concerns regarding fraud impacting BCBSNE or its members, please reach out to the SIU Hotline: 1-877-632-2583.
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