Identify Fraud & Abuse

At Blue Cross, our goal is the same as yours – to ensure that our customers and your patients receive the best available health care. Annual billion dollar losses in the health care industry each year can block the achievement of this goal.

Blue Cross and Blue Shield of Alabama already monitors claims and stays in contact with providers to detect and review possible cases of fraud and abuse.

However, we can do more to eliminate this problem. Below, we've provided some basic information about fraud and abuse and a link to report suspected fraud and abuse.

Examples of fraud include:

• Billing for services not provided
• Using an incorrect or inappropriate provider number to be paid
• Signing blank records or certification forms that are used by another entity to obtain payment
• Falsifying information on applications, medical records, billing statements and/or cost reports
• Misrepresenting non-covered services as medically necessary, by using inappropriate procedure or diagnosis codes
• Offering incentives to Blue Cross and Blue Shield of Alabama patients that are not offered to non-Blue Cross and Blue Shield of Alabama patients (e.g. routinely waiving or discounting the Blue Cross and Blue Shield of Alabama deductible or coinsurance amounts.)

Examples of abuse include:

• Using procedure or revenue codes that describe more extensive services than those actually performed
• Billing for services grossly in excess of those needed by patients
• Charging more than actual purchase price for a service, item or drug
• Incorrectly apportioning costs on cost reports

Report fraud and abuse:

Complete the online form to report suspected fraud and abuse or call our hotline at 1 800 824-4391.

Protecting your practice:

• Have a process in place to keep up with benefit and policy changes released in Blue Cross and Blue Shield of Alabama written and online publications.
• Don't waive Blue Cross and Blue Shield of Alabama deductibles and/or coinsurance.
• Keep your provider number confidential and don't allow other providers to bill for their services with your provider number.
  Carefully, review all documentation before certifying the medical necessity of services or supplies needed/requested by patients.
• If someone else is authorized to bill for your services, have a process in place to ensure those billing accurately reflect the services provided.
• Maintain a treatment record for each patient and document all services, orders and prescriptions.
• Have internal audits in place to detect billing inaccuracies promptly.
• Make copies of each patient's insurance card and driver's license.
• Don't advertise "free" services that are subsequently billed to Blue Cross and Blue Shield of Alabama.
• Don't bill Blue Cross and Blue Shield of Alabama for services provided to a relative who is related by blood or marriage or who lives in the provider's household.