Policies and Best Practices
Fraud, waste, and abuse
Find out how to report and fight health care fraud, waste, and abuse (FWA).
What is health care fraud, waste, and abuse?
layout
vertical-left
theme
white
media-type
none
gradient
true
title
Fraud
heading-level
h3
heading-size
sm
rte-description
An intentional or criminal misrepresentation resulting in personal or financial gain.
layout
vertical-left
theme
white
media-type
none
gradient
true
title
Waste
heading-level
h3
heading-size
sm
rte-description
Practices that, directly or indirectly, result in unnecessary costs, such as overusing services. Waste is generally not considered to be caused by criminally negligent actions but rather by the misuse of resources.
layout
vertical-left
theme
white
media-type
none
gradient
true
title
Abuse
heading-level
h3
heading-size
sm
rte-description
A reckless disregard or conduct that goes against and is inconsistent with acceptable business and/or medical practices resulting in greater reimbursement or services.
Types of health care fraud
layout
vertical-left
theme
white
media-type
icon
icon
lh-icon--doctor
icon-size
xl
gradient
true
title
Provider-related fraud
heading-level
h3
heading-size
xxs
title-alt
true
rte-description
- Phantom billing – When a provider charges for services that weren't performed or equipment that wasn't delivered.
- Upcoding – When a provider bills an insurer for a service that's more expensive than what was actually provided, such as billing for a specialist when the patient saw a nurse or an intern.
- Overutilization/unnecessary care – When a provider conducts or requests unnecessary tests, surgeries, or other procedures to obtain additional payments or referral fees.
- Misrepresenting services – When a provider conducts non-covered procedures on a patient and then submits claims to the insurer for different services that are covered under the patient’s plan.
- Unbundling – When a provider bills an insurer separately for parts of a single procedure.
layout
vertical-left
theme
white
media-type
icon
icon
lh-icon--user
icon-size
xl
gradient
true
title
Non-provider related fraud
heading-level
h3
heading-size
xxs
title-alt
true
rte-description
- Masquerading as a health care professional – When an individual or group delivers health care services or equipment to a patient without a proper license.
- Identity theft – When an individual uses another person’s health insurance or personal information to access health care services.
- Doctor shopping – When a patient visits multiple practitioners to get several prescriptions for controlled substances.
- Falsification – When an individual or group files fake claims to an insurer or alters amounts charged on claim forms or prescription receipts.
How do we fight health care fraud?
At Blue Cross and Blue Shield of North Carolina (Blue Cross NC), our mission is to improve the health and well-being of our customers and communities. One of the ways we do that is by working hard to protect our members, providers, agents, and business partners from health care fraud, waste, and abuse. This helps lower health care costs, protects personal information, and prevents future threats.
To maximize our ability to prevent FWA, Blue Cross NC relies on its Special Investigations Unit (SIU). Our SIU works collaboratively with internal partners and external bodies, such as law enforcement and delegated entities, to identify, report, and prevent FWA.
How health care fraud impacts you
The impact of health care fraud is widespread and affects providers, consumers, patients, communities, and businesses within the entire health care system. Between 4% and 10% of all health care expenditures are estimated to be potentially fraudulent. This loss directly impacts providers, patients, insurers, and government agencies through higher health care costs. Additionally, health care fraud often hurts patients who may be subjected to unnecessary or unsafe procedures or who may be the victims of identity theft.
What you can do
Our biggest ally in the fight against health care fraud is you, our member. There are several ways you can protect yourself while helping to curb health care fraud in North Carolina.
- Safeguard your insurance card by treating it the same as a credit card. Don’t lend your insurance card to others. Doing so is not only potentially criminal, but it can also pose a health risk to you through inaccurate medical records.
- Beware of free services, especially if you’re asked to provide your insurance card. The service may not be free and could be fraudulently charged to your insurance company.
- Closely examine your Explanation of Benefits (EOB), which you should receive in the mail following a doctor or hospital visit. Ensure the dates, places, and services billed were the ones you received.
Blue Cross NC partners with providers in the battle against health care fraud. We depend on you, our allies at the frontlines, to identify and report potential cases of fraud. Become familiar with the potential types of health care fraud so you can protect your patients, yourselves, and our communities.
How to report health care fraud
You have four options for reporting suspected fraud, waste, and abuse: online form, phone, email, or postal mail. When reporting, please provide as much information as possible to help our investigation team conduct a thorough review of the concern. One of our team members may reach out to you to gather additional information.
layout
vertical-left
theme
white
media-type
icon
icon
lh-icon--file
icon-size
xl
gradient
true
title
Online report form
heading-level
h3
heading-size
xxs
title-alt
true
rte-description
Submit our online Fraud and Abuse Report Form. You can remain anonymous.
cta1-variant
outlined
cta1-text
Complete Report Form
cta1-analytics-id
card-1-3b270ee9ae-c748ab21e4-commonforms.bcbsnc.com/fraud-and-abuse-report-form
layout
vertical-left
theme
white
media-type
icon
icon
lh-icon--phone-call
icon-size
xl
gradient
true
title
Confidential hotline
heading-level
h3
heading-size
xxs
title-alt
true
rte-description
Call to report FWA with our 24-hour confidential hotline.
cta1-variant
outlined
cta1-text
800-324-4963
cta1-href
cta1-analytics-id
card-1-94eb1e3f0f-91ff059665-tel:1-800-324-4963
cta2-variant
text
cta2-text
919-765-2464
cta2-href
cta2-analytics-id
card-2-94eb1e3f0f-2a04e9ada8-tel:1-919-765-2464
layout
vertical-left
theme
white
media-type
icon
icon
lh-icon--envelope-simple
icon-size
xl
gradient
true
title
Email
heading-level
h3
heading-size
xxs
title-alt
true
rte-description
Email our SIU team at SIU@bcbsnc.com to report suspected FWA.
Note: Email may not be secure. We cannot guarantee the privacy of information sent by email. Please use caution when providing personal information. It is best to only provide enough information for the SIU to contact you.
cta1-variant
outlined
cta1-text
Email SIU
cta1-href
cta1-analytics-id
card-1-a9893ea6ba-2a58954261-mailto:SIU@bcbsnc.com
layout
vertical-left
theme
white
media-type
icon
icon
lh-icon--mailbox
icon-size
xl
gradient
true
title
Mail
heading-level
h3
heading-size
xxs
title-alt
true
rte-description
Report suspected FWA by mailing our SIU team:
Blue Cross NC SIU
PO Box 25431
Durham, NC 27702-5431