“Every time you get an explanation of benefits , EOB, take a look at it. Make sure the information on them is accurate and that the date of service is actually the date of service and that the service was the one provided to you,” Saccoccio says. “If you find something that is incorrect, call your insurance company.”
Following a thorough review of the EOB, dispose of it properly to avoid potential identity theft, the BCBSA recommends.
Raising Your Fraud IQ
BCBSA's Sneed says patients should be informed, keep good records, and use common sense. Anything that comes across as a free service in exchange for insurance information should be a red flag, he says.
“There have been cases where the patients actually have been part of the fraud,” Saccoccio says. “They’ve actually undergone procedures in order for the physician to generate billing for that procedure but either in return for a cash payment or free cosmetic surgery. If someone is offering you free health-care services if you give us your insurance number or your Medicare number, you have to be very wary of that because they could be trying to collect information to file false claims.”
If a co-pay or deductible gets waived, that’s another red flag, Sneed says. BCBSA recommends reporting instances where co-payment or deductibles are waived, as it is a common indicator that a provider is obtaining inflated payments, which result in insurance premium increases for everyone. A patient should never sign blank insurance claims either, he advises.
What Providers Can Do
In addition to the BCBSA National Anti-Fraud Department(NAFD), Sneed says, each independent Blue Plan has its own anti-fraud unit. One of the most successful components of an investigative team is having a diverse staff, he says.
Years ago, a large number of those doing the “gumshoe” work were retired from the police force. Today, Sneed says, having people who have a clinical and medical background can recognize when a diagnosis doesn’t match the services provided. Another asset is using technology to analyze emerging trends and schemes, he says.
Portice of Verisk Health says with health-care reform becoming a national dialogue, there is a greater awareness among consumers of where money is being spent and an escalated awareness of the tremendous amount being lost.