Health Care Fraud

Fraud is an intentional misrepresentation by either providers or consumers to obtain services, obtain payment for services, or obtain claim program eligibility. According to the National Health Care Anti-Fraud Association, they estimate that annually health care fraud accounts for $60 billion of overall health care spending.

Some examples of health care fraud include:

• Intentionally billing for services, procedures and/or supplies that were not provided
• Intentionally billing for more expensive services than what were provided
• Intentionally billing for additional, unnecessary treatment
• Intentionally misrepresenting non-covered treatments as medically necessary covered treatments
• Intentionally altering or falsifying claims
• Allowing someone who is not covered by the insurance contract to use the health insurance identification card to obtain services
• Trying to add an ineligible person to a contract
• Submitting false information to obtain coverage

Very few people commit health care fraud activities. Yet the impact is costly and significant. It also has an adverse effect on health care premiums and copayments.

How Can You Help?

We need your help in controlling the extra expense created by fraud. As the person most knowledgeable about your medical treatment, you should review your Explanation of Benefits sheet. Verify you received the services charged to BCBSND and report any questionable charges.

If you have questions regarding charges on your Explanation of Benefits sheet, or about your benefit plan, please contact Member Services at 1-844-363-8457.

If you suspect fraudulent activity, you can report it in one of three ways to the Special Investigations Unit:

• Call our fraud hotline at 877-537-2830 or 701-281-8610 locally.
• Contact us by email at BCBSND Special Investigations Unit.
• Write a letter and send it to our post office box (Compliance, P.O. Box 242, West Fargo, ND 58078-0242).

Please include as much information as you have, such as:

• Date of Incident
• Provider Information (Name, Practicing location)
• Policy holder information
• Your contact information if you choose to provide it

Confidentiality and Anonymity

It is the policy of the Special Investigations Unit to keep the identity of the reporting party confidential to the fullest extent possible. If you are not comfortable giving us your name when you make a report, you can use either the hotline number or the post office box to make an anonymous report.

How Can You Protect Yourself?

Safeguard your health insurance identification card/benefit plan number Beware of "free" services, especially if you are asked to provide your health insurance identification card/benefit plan number. The service may not be free and could be a ‘scheme' designed to bill you or BCBSND.

The Federal Trade Commission (FTC), the nation's consumer protection agency, published the free consumer brochure, Medical Identity Theft. The 6-page publication explains how medical identity theft occurs, how it differs from traditional identity theft, offers tips to minimize your risk and how to recover should you experience medical identity theft.

If you have questions regarding charges on your Explanation of Benefits sheet, or about your benefit plan, please contact Member Services at 1-844-363-8457.