ST. PAUL, Minn. -- Through aggressive health care fraud investigations and coordination among other states' Blue Cross plans, the Blue Cross Special Investigations Unit (SIU) stopped payment on $8.7 million of suspect claims last year, reducing the impact of fraud on premiums in Minnesota.

"Our experience has been that the overwhelming majority of providers and consumers act ethically and responsibly in submitting their health care bills; however, there are exceptions who are trying to make money illegally at the expense of payers," said Dave Bohnenstingel, SIU manager. "Unfortunately, those fraud losses must be borne by our customers in the form of higher premiums."

Using sophisticated computer software, communication with Blues plans throughout the country, analysis of large claims, and tips to their fraud hot line, Blue Cross' SIU looks for irregularities or other "red flags" in claims submitted by providers or members.

A fraud scam that is currently popular is known as the "rent a patient" scheme. In this scam, marketers recruit low income or minority patients, paying them several hundred dollars and often transporting them to clinics solely for unnecessary diagnostic tests or surgery. The clinics then bill the insurance company an inflated amount for procedures that were done. The majority of the claims stopped by Blue Cross' SIU in 2003 is believed to be attributable to this scheme.

In fact, Blue Cross has been working with the Blue Cross and Blue Shield Association and the FBI in an ongoing investigation of more than 150 providers in California who are suspected of engaging in the rent-a-patient scheme. The FBI raided three of the surgery centers last month. Blue Cross is considering its legal options against the providers.

Blue Cross and Blue Shield of Minnesota has more than two decades of experience in detection and prevention of health care fraud.  As one of the pioneers of developing an anti-fraud program, Blue Cross formalized an aggressive anti-fraud program more than 10 years ago.

 

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