## Overview ## Healthcare fraud is theft by deception It's a serious concern for the entire healthcare industry. According to estimates from the National Health Care Anti-Fraud Association (an industry trade group), 3-10% of what Americans spend on healthcare is lost to fraud every year — that’s between $30 billion and $140 billion a year. ## What we’re doing about it We investigate fraud through our Special Investigations Unit (SIU). This group works aggressively to address issues and concerns about fraud and abuse. The SIU’s mission is to prevent, detect, investigate and report fraud. When appropriate, they also recover money lost to healthcare fraud and abuse. The SIU works with members and their doctors and clinics to address fraud and abuse situations. ## Examples ## Examples of healthcare fraud ### Doctor shopping When individuals visit multiple physicians or emergency rooms to obtain several prescriptions for controlled substances ### Identity swapping Allowing an uninsured person to use another individual's insurance cards ### Identity theft The illegal use of another person's personal information to obtain medical services or prescription drugs ### Ineligible dependents Keeping an ex-spouse, former dependent, or even non-family members on an health insurance policy ### Services not rendered Billing for services or prescriptions that were never provided or dispensed ### Unbundling Billing separately for procedures and supplies that should be grouped under a single procedure or global fee ### Upcoding When a provider submits a claim for a more expensive service, supply or piece of equipment than what was actually provided ### Telemarketing fraud Involves providers not directly engaged in patient care using telemarketers to promote high-cost medical products or services ### Misrepresenting services Billing procedures under different names or using alternative Current Procedural Terminology (CPT) codes to obtain coverage for services not typically covered—such as cosmetic or experimental treatments ### Kickbacks When providers exchange money or things of value for the referral of patients for services that are not medically necessary or have no validity or diagnostic value, as well as waiving copays and/or deductibles ### Durable Medical Equipment (DME) fraud When DME companies use multiple provider numbers or business names to bill for both the rental and purchase of the same equipment. They might also bill for equipment or supplies never received by the patient. ## Reporting fraud ### What you can do Members should always check their Explanation of Benefits (EOB) statement to make sure the charges from your providers are correct. Be aware of the many types of fraud that can occur. If you see something concerning, please report it. ### Contact us If you suspect fraud, please call us at **1-800-382-2000**, ext. **28363**, [submit a report online](https://secure.ethicspoint.com/domain/media/en/gui/83442/index.html) or email . You do not have to give your name. If you are calling after hours, please leave a message. You can also mail or fax: Blue Cross and Blue Shield of Minnesota Special Investigations Unit P.O. Box 64560 St. Paul, MN 55164-0560 Fax: (651) 662-1099