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FRAUD HOTLINE
1-800-FRAUD21
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Fraud and Abuse
What is health-care fraud, and why is it a problem?
Fraud occurs when a dishonest member or provider lies on an application or claim
form with the intention of receiving a payment from BlueAdvantage Administrators
of Arkansas 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 accounts for between 3 and 10 percent of the annual expenditures
for health care in the United States. We all pay the price through higher premiums
and health-care costs.
What are common types of fraud?
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Providing false statements on an application;
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Submitting claims for services that were not performed;
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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 EOB (Explanation of Benefits) carefully. The EOB is your notification
that BlueAdvantage has paid a claim under your health-benefit plan. Look for:
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Incorrect dates of service;
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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.
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SPECIAL INVESTIGATIONS UNIT MISSION STATEMENT
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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.
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