How We Fight Fraud

Blue Cross Blue Shield of Michigan investigates tips reported to our Fraud Hotline. We work with local, state and federal authorities to bring people who commit health care fraud to justice.

Since 1980, our Corporate and Financial Investigations Unit has recovered more than $333 million. The Corporate and Financial Investigations Unit detects, investigates and seeks prosecution of fraud cases in which corporate assets are lost.

The CFI Federal Programs Unit detects, corrects and prevents fraud, waste and abuse as defined by the Centers for Medicare and Medicaid Services to protect the Medicare Trust Fund. This unit investigates all cases of fraud against government programs and takes completed investigations to the appropriate governmental agency.

Members of our investigative staff use a combination of talents in order to uncover fraud. They have experience in complex financial investigations, interview and interrogation, check and credit card fraud, narcotics, organized crime, surveillance, undercover operations, consumer fraud and police administration. The remainder has expertise in the areas of benefits, claims processing, auditing, accounting and finance, technology and security.

Director's Blog: Identify and protect yourself from COVID-19 related scams (PDF)

Did you know? Blue Cross Blue Shield of Michigan became the first insurer in the U.S. to launch its own health care fraud investigations unit in July 1980.

New fraud software helps prosecute fraud crimes

Blue Cross Blue Shield of Michigan began using fraud software in May 2008 to detect fraud, waste and abuse patterns in our Medicare Advantage claims. 

This web-based software is used by Blue plans across the country, and has become a valuable tool in monitoring abnormal billing patterns by doctors and facilities. It finds higher-than-normal prescription drug purchases by members, and helped us launch a number of fraud investigations that resulted in criminal prosecution and arrest warrants.

Because of the success of this software, we're expanding the use of proactive measures to review claims submitted for every benefit plan.

 

How you can fight fraud

The number one thing you can do is to report health care fraud when you suspect it. You can:

You can also protect yourself against fraud by knowing what it looks like, and how scam artists operate.