St. Paul, Minn. - Through aggressive health care fraud investigations and coordination among other states' Blue Cross plans, the Special Investigations Unit (SIU) of Blue Cross and Blue Shield of Minnesota stopped payment on more than $3 million of suspect claims last year, reducing the impact of fraud on premiums in that state. By comparison, Blue Cross stopped $8.7 million in claims in 2003, most of which was due to the rent-a-patient scams now being investigated and prosecuted in Southern California."We saved millions of dollars of our members' premium dollars, because we were able to identify the scam early and stop payment on fraudulent claims," says Dave Bohnenstingel, SIU manager. "In fact, Blue Cross and Blue Shield of Minnesota was integral in bringing the scam to light and the perpetrators to justice," he added.

Bohnenstingel credited the drop in suspect claims in 2004 to the fact that the rent-a-patient scam is now essentially defunct. In the spring of 2004, the FBI raided several suspected clinics as part of its investigation of 150 clinics, eventually bringing federal charges against several of the individuals involved. In this scam, marketers recruited 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 billed the insurance company an inflated amount for the procedures. The investigations continue, but the fraudulent activity seems to have subsided."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," Bohnenstingel says. "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. Blue Cross works with purchasers, the National Health Care Anti Fraud Association and several law enforcement agencies to combat fraud. As the state's largest health plan, Blue Cross also spearheaded the creation of a workgroup with other Twin Cities' health plans to share information regarding local scams. The national Blue Cross and Blue Shield Association estimates that between 3% and 5% of the dollars spent on health care in the United States in a year is lost to fraud.Source: Blue Cross and Blue Shield of Minnesota

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