ST. PAUL, Minn., May 3 /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 $8.7 million of suspect claims last year, reducing the impact of fraud on premiums in Minnesota.
“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,” said Dave Bohnenstingel, SIU manager. “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 irregularities or other “red flags” in claims submitted by providers or members.
A fraud scam that is currently popular is known as the “rent a patient” scheme. In this scam, marketers recruit 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 bill the insurance company an inflated amount for procedures that were done. The majority of the claims stopped by Blue Cross’ SIU in 2003 is believed to be attributable to this scheme.
In fact, Blue Cross has been working with the Blue Cross and Blue Shield Association and the FBI in an ongoing investigation of more than 150 providers in California who are suspected of engaging in the rent-a-patient scheme. The FBI raided three of the surgery centers last month. Blue Cross is considering its legal options against the providers.
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 $1.3 trillion spent on health care in the United States in a year is lost to fraud. It is estimated that the rent-a-patient scheme alone has cost health care plans in the U.S. nearly $500 million in the past two years.
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 permanently 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.
Blue Cross and Blue Shield of Minnesota
CONTACT: Joel Swanson, +1-651-662-2882, Pager +1-651-629-3961, orKarl Oestreich, +1-651-662-1502, Pager +1-651-610-7422, both of Blue Cross andBlue Shield of Minnesota
