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Health Care Fraud: The $80 Billion Crime

By Blue Cross NC | July 2, 2014 | Healthy Lifestyle, Industry Perspectives

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In a nation that spends a few trillion dollars a year on health care, there are bound to be some who try to take advantage of the system for their own gain. After all, it’s just a drop in the bucket, right? Wrong. These fraudulent actions have a big and expensive impact.

In 2013, the FBI estimated that health care fraud costs the U.S. $80 billion every year. Other estimates go even higher.

Those high costs lead to increased spending on health care for you, us and others in the health care system. And as health care costs rise, so do health insurance premiums.

What Does Health Care Fraud Look Like?

Health care fraud can take many forms. Our broad range of medical conditions and treatments, the complexity of our system and the high number of patients all provide a breeding ground for fraud – which often is difficult to detect.

Most doctors and hospitals are honest, but there have been instances of some committing fraud in these ways:

  • Creating a false diagnosis to justify tests, surgeries or other procedures that aren’t medically necessary
  • Billing for a higher priced treatment when a lower cost treatment was performed
  • Billing for procedures that were never performed

Patients sometimes also take advantage of the system. They might use an insurance card that doesn’t belong to them, add someone to their policy who isn’t eligible for coverage or request doctors to falsely submit a claim so a non-covered service will be paid for by insurance.

These fraudulent actions not only cost money, but they cause harm. Fraud schemes that add false medical conditions or treatments to a patient’s medical record put patients at risk of injury or even death from harmful future treatments based on the false data.

How We Fight Fraud and Abuse

To protect our customers, we have a Special Investigations Unit dedicated to identifying and fighting fraud.  BCBSNC’s Special Investigations Unit is made up of trained professionals who review all allegations of suspected fraud and abuse.

We also detect fraud with software that identifies and analyzes unusual health care usage patterns. And we partner with anti-fraud associations to share intelligence and keep up-to-date on the latest trends.

Our efforts are paying off. Recently, our Special Investigations Unit uncovered a $4.5 million federal fraud scheme. By identifying this, we’re taking strong steps to protect our customers.

Your Role As Patient

We’re doing our part to help fight health care fraud, and you can help too. Here are four things you can do to prevent fraud and abuse:

  • Review your Explanation of Benefits (EOB) to ensure accurate dates, names and services are reported.
  • Keep your insurance card and personal information in a safe, secure place.
  • Count pills when you pick up a prescription to make sure the prescription was filled accurately.
  • Report suspected abuse by calling our confidential Fraud Hotline (1-800-324-4963) or visiting our fraud website.

Some more important tips:

  • Never give out your Social Security, Medicare, and health plan numbers or banking information to someone that you don’t know.
  • Carefully review your plan statement to ensure all the information is correct.
  • Know that free services DO NOT require you give your plan or Medicare number to anyone.
  • Share this information with your friends.

If you have suspicions of fraud, waste, or abuse, report them immediately to BCBSNC’s Special Investigations Unit.

Together, we can all do our part to fight medical fraud. We welcome your comments on Facebook or Twitterwith the hashtag #letstalkcost.


Fraud Hotline:  1-800-324-4963

Fax: 919-765-7753



Special Investigations Unit, Blue Cross and Blue Shield of North Carolina. P.O. Box 2291 Durham, North Carolina