How We Fight Health Care Fraud

The Corporate and Financial Investigations, or CFI, team staff at Blue Cross Blue Shield of Michigan is composed of:

• Health care fraud investigators
  
• Hotline specialists
  
• Special investigative analysts
  
• Data technology and advanced analytics analysts
  
• Professional coders
  
• Registered nurses

The staff certifications include accredited health care fraud investigators, certified fraud examiners, certified professional coders and registered nurses.

The investigative team is dedicated to proactive data mining across all lines of business using current data analysis tools. The team possesses expertise in medical coding, clinical experience, and data analysis. Algorithms are used to analyze claim files to identify suspected fraud, waste or abuse. The team strives to proactively identify irregularities to protect our customers.

CFI has an established Government Programs Investigative Team that was formed to comply with the guidelines created by the Centers for Medicare & Medicaid Services. Key functions include strategies to address and reduce fraud, waste and abuse, or FWA, across the enterprise, including Medicare, Medicaid and the Federal Employee Program. The team investigates all allegations of fraud against government programs and refers completed investigations to the appropriate governmental agency.

CFI monitors a fraud hotline for employees, members and providers to report concerns of potential fraud. Hotline specialists answer calls from 8:30 a.m. at 4:30 p.m. daily and callers can leave a voicemail message after hours. Callers can choose to remain anonymous. Blue Cross Blue Shield of Michigan maintains a policy which enforces non-retaliation and non-intimidation against those who report potential concerns.

Members can also report fraud through the Blue Cross Blue Shield of Michigan mobile app.

• Review your medical bills to verify that the services rendered and amounts billed are correct.
• Review your Explanation of Benefits, or EOB, which is mailed to you or available online after receiving health care services. Verify that the dates and services billed are correct. Prescription and pharmacy claims data is not listed on an EOB. Members can view this information in their online account or in the mobile app.
  
• Protect your health insurance identification card and contract information like your social security card. Do not share your contract number with an unverified source.
  
• Beware of services listed as free. Even if the patient is not being charged the provider can still bill BCBSM.
  

• Verify patient identity - Ask for picture ID to ensure that the person with the BCBSM subscriber card is the owner of that card.
• Use proper billing codes - Consult CPT and International Classification of Diseases code book and other resources to verify that  the codes being used are appropriate and accurate.
  
• Check patient history - To help prevent prescription fraud, ask patients if they have obtained prescriptions from other doctors. Check their Michigan Automated Prescription System, or MAPS, reports.
  
• Safeguard prescription pads - Prescription pads should not be left accessible to patients. Prescription fraud schemes often use stolen prescription pads or compromised e-prescribing passwords.
  
• Make patient agreements - Enter into controlled substance or narcotics contracts with patients to express the importance of limiting medication use as well as checking the potential for addictive behaviors.