Fraud and Abuse Overview

The Blue Cross and Blue Shield Association (BCBSA) and the National Insurance Association of America (NIAA) estimate that between 5-10% of all claims nationwide are incorrectly paid due to fraudulent or abusive billing practices. Regence cooperates with providers, facilities, and law enforcement agencies to identify and stop health care fraud and preserve health care quality and affordability.

Health care fraud is the intentional, unlawful and repetitive practice of filing fraudulent or deceptive claims for reimbursement. The following practices have been identified by the BCBSA as examples of fraud:

• Billing for services not rendered
• Deliberately submitting false claims
• A patient presenting a false member card
• Purposely misrepresenting a condition or the types of services provided
• Intentionally omitting information about a condition, symptom or service provided

Inadvertent errors, such as occasionally reporting the wrong billing code, are not considered fraudulent.

Preventing Fraud

The following practices can help protect your office from intentional or inadvertent fraud:

• Verify that billing codes are accurate.
• Protect your prescription forms, which are often stolen during medical visits and used in pharmacy fraud schemes.
• Check patient histories to help prevent prescription medication fraud. Ask patients if they are seeing or have obtained prescriptions from other providers.
• Implement procedures to ensure that information, such as the nature of services provided, is accurately communicated to your billing staff and to any third-party firms and services.

Learn more about how to protect your office from fraudulent activities