Fraud, Waste and Abuse Program
Studies have determined that healthcare fraud is the single largest contributor to the increase in healthcare costs. It's a serious crime and accounts for an estimated 3-10% of all healthcare spending. We take it very serious and are committed to fight against it.
Common Examples of Fraud, Waste and Abuse
Fraud, waste and abuse occurs in a variety of ways. The most common include:
- Provider Actions
- Billing for services or supplies that were not provided or needed
- Filing a claim for a more expensive procedure than was actually performed
- Billing for a covered service when the true service was non-covered
- Omitting or misrepresenting information about a condition, symptom or service performed
- Member Actions
- Using an insurance ID card that belongs to someone else
- Adding someone to a policy who is not eligible for coverage
- Receiving narcotic prescriptions from several physicians, through deceit
- Forging or altering bills or receipts
How We Fight Against Fraud, Waste & Abuse
At Blue Cross and Blue Shield of Vermont we take a proactive approach to detecting and investigating potential fraud, waste and abuse.
- We have a special investigative unit dedicated to preventing, detecting and investigating FWA, staffed with trained professionals who have many years of health care and health insurance experience.
- We use sophisticated software to continually analyze our healthcare claim patterns and investigate red-flag situations were provider billing exceeds normal ranges.
- We partner with industry-leading firms who specialize in identifying “outlier” claims and auditing provider’s records to ensure billings are correct.
- We maintain an active fraud hotline where our members and providers may report suspected fraud.
- We recover millions of dollars in erroneous and unsupported claims every year.
What you can do
Help us control rising healthcare costs. If you suspect fraud, waste, or abuse in the healthcare system, you should report it to Blue Cross and Blue Shield of Vermont and we will investigate. Your actions may help to improve the healthcare system and reduce costs for our members, customers, and business partners.
Tips when reviewing your Summary of Health Plan Payments (SHPP)
Help us identify potential FWA situations by reviewing your explanation of benefits or claims (available within our secure Member Resource Center) to ensure that reported services where actually received. During your review please keep these sometimes confusing scenarios in mind:
- Some healthcare service providers bill for two components: facility and professional. For example, if you receive laboratory, x-ray and imaging services you will likely see two separate lines on your Summary of Health Plan Payments. It’s normal and expected to see two separate provider names on your Summary of Health Plan Payments in these scenarios (example below). It’s not considered fraud, waste or abuse.
- Hospital where the x-ray or laboratory services were performed (facility component)
- Doctor who read the x-ray or laboratory service (professional component)
- Injections/Immunizations, intravenous (IV) and blood draws fall under the type of service (TOS) category ‘Surgery.’ Although these types of services aren’t what typically come to mind when you think surgery, this is how they would appear on your Summary of Health Plan Payments.
Report suspected fraud, waste, or abuse to us
You may remain anonymous if you prefer. All information received or discovered by the Blue Cross and Blue Shield of Vermont FWA Special Investigations Unit (SIU) will be treated as confidential, and the results of investigations will be discussed only with persons having a legitimate reason to receive the information.
- Call the Blue Cross and Blue Shield of Vermont Fraud Hotline:
- (833) 225-3810 for Blue Cross and Blue Shield of Vermont Members (non-FEP)
- (800) 337-8440 for FEP Members
- Email Fraud_issues@bcbsvt.com
- Write to us at
Blue Cross and Blue Shield of Vermont
PO Box 186
Montpelier, VT 05601-0186
Attn: Fraud, Waste, Abuse & Recovery Department