Free money

An anonymous caller advised Blue Cross Blue Shield of Michigan Corporate and Financial Investigations (CFI) that Jane Doe was receiving checks from Blue Cross for services rendered. The caller didn’t have all the details, but believed that Jane Doe was receiving the checks fraudulently. 

CFI Investigators learned that Jane Doe had been receiving checks for lab work being completed for a drug addiction during her pregnancy. In less than a year, Jane Doe had lab work at four different labs around the country. Each lab was contacted. All said they had not been paid for services provided. Jane Doe’s physicians ordered the labs as part of her treatment plan. The lab work was completed and the results were provided to her physicians.

During her interview with investigators, Jane Doe said that a friend told her about this scheme to get “free money” from Blue Cross.

During the investigation, each lab told the same story:

  • A doctor would send a urine/blood sample for testing.
  • The lab would send the results to the requesting doctor and submit a claim to Blue Cross.
  • Because these lab facilities are non-participating, a check in the amount of the claim would be sent to the subscriber instead of the lab.
  • The lab was notified that the subscriber Jane Doe, received the checks from Blue Cross to cover the lab services. 
  • After a reasonable amount of time, the lab facilities sent Jane Doe bills for the services rendered.
  • Requests for payment were ignored.

Jane Doe received more than $57,000 from Blue Cross in less than a year for the lab services rendered. She admittedly used this money to purchase narcotics and said she had no intention of paying the labs. Lab employees told investigators that this type of scheme is common in non-par cases such as this one. Most of the time, payment is never recovered.

The problem is that labs are performing services (blood/urine testing) for the provider, but aren’t getting paid by the member for whom the services are performed. Ideally, the provider collects payment from the patient up front (non-par). Then, the patient is reimbursed by the insurance company for out-of-pocket expenses. Unfortunately, in this case, the labs didn’t have any contact with the member when the services (lab screens) were rendered. Here’s how it works:

  • The member goes to the physician.
  • The physician takes a urine or blood sample from the member.
  • That sample is sent to a lab for a drug screening.
  • A claim is submitted from the lab to Blue Cross.
  • The lab also sends a bill to the member.
  • Blue Cross then sends a check to the member who is supposed to pay the bill from the lab with that check.

CFI has learned that word is spreading about this scheme to get free money from the insurance companies.  

Blue Cross investigators have turned this case over to law enforcement for possible prosecution.

If you suspect health care fraud, waste or abuse, please phone the Blue Cross Corporate & Financial Investigations Anti-Fraud Hotline at 1-800-482-3787.