Members

Fraud and Abuse

FRAUD HOTLINE
1-800-372-8321


Report Fraud and Abuse

What is health-care fraud, and why is it a problem?

Fight Fraud

Fraud occurs when a dishonest member or provider lies on an application or claim form with the intention of receiving a payment from Arkansas Blue Cross and Blue Shield to which they are not entitled.

As stated in the Health Insurance Portability and Accountability Act (HIPAA) of 1996 (18USC, Ch. 63, Sec 1347):

Whoever knowingly and willfully executes, or attempts to execute, a scheme or artifice to defraud any health-care benefit program; or to obtain, by means of false or fraudulent pretenses, representations, or promises, any of the money or property owned by, or under the custody or control of, any health-care benefit program, in connection with the delivery of or payment for health-care services, shall be fined under this title or imprisoned not more than 10 years or both.

Fraud and abuse is estimated to account for between 3 and 10 percent of the annual expenditures for health-care in the United States.

What are common types of fraud?

  • Providing false statements on an application;
  • Submitting claims for services that were not performed;
  • Misrepresenting services that were provided;
  • Providing medically unnecessary services.

What are the penalties for committing health-care fraud?

Health-care fraud is both a state and federal offense. As stated in the HIPAA Act of 1996: (18USC, Ch. 63, Sec 1347), a dishonest provider or member is subject to fines or imprisonment of not more than 10 years or both. Making false or misleading statements on an application carries a maximum five-year sentence.

You can help!

Read your explanation of benefits (EOB) carefully. The EOB is your notification that Arkansas Blue Cross has paid a claim under your health-care benefits plan. Look for:

  • Incorrect dates of service;
  • Services that you did not receive;
  • Non-laboratory or non-X-ray providers that did not see or treat you.

Fraud Hotline

Call the Fraud Hotline at 1-800-372-8321 any time day or night. All tips are kept strictly confidential.

Arkansas Blue Cross and Blue Shield
SPECIAL INVESTIGATIONS UNIT MISSION STATEMENT

The detection, prevention and elimination of fraud, abuse and over-utilization are essential to maintaining a health-care system that is affordable for everyone now and in the future.

We aggressively investigate and pursue the prosecution of the perpetrators of health-care fraud, abuse and over-utilization, including providers of medical and other related health services, agents, members and others.

We actively cooperate with criminal investigations conducted by federal, state and local authorities, encourage education and conduct awareness programs to alert our employees, members and the general public to potential fraud or abuse.