October > Be a Wise Healthcare Consumer
Health Care Fraud: What UT SELECT Participants Should Know
Health care expenditures make up a large part of federal and state budgets, and certainly most family budgets, too. In the United States, more than $2 trillion is spent on health care every year. The National Health Care Anti-Fraud Association estimates that at least 3% (more than $60 billion annually) of health care expenditures are related to health care fraud1. Health care fraud costs the average family of four over $200 a year2.
What is health care fraud?
Health care fraud is the intentional submission or filing of a false claim(s) for the purpose of obtaining an unauthorized benefit for the individual or the entity filing the claim.
The most common kind of fraud involves providing a false statement or a misrepresentation of facts that are critical to the determination of how to pay benefits. Examples of fraudulent acts include:
- Billing for services, procedures and/or supplies that were never provided or performed (phantom claims),
- Duplicate claims submissions,
- Unbundling services from a group of services in order to increase medical payment and
- Performance of medically unnecessary services or procedures.
Who commits health care fraud?
Individuals who are drawn to and working in the health care profession are overwhelmingly noted for having high ethical standards. However, there are a small number of individuals and entities involved with the delivery of health care that do commit health care fraud, including individual practitioners, pharmacists, billing services, equipment suppliers and other providers.
There have also been documented cases in which patients have willingly participated in fraudulent practices. One common example would involve patients undergoing unnecessary procedures in order to generate billing for the physician in exchange for other free services3.
What can you do to help prevent health care fraud and abuse?
Fraud and abuse raise the costs of health care for everyone. So, each of us has a stake in reducing health care fraud. To protect yourself as well as the UT SELECT Medical plan from possible fraud:
- Always review your explanation of benefits (EOB) statements to verify information such as name, date of service, diagnosis and the services listed to make sure the information is accurate.
- Raise your health care IQ and ask your doctor to explain the reason for any services ordered.
- Report any discrepancies to your insurance company4.
If the billing for health care services you have received seems suspicious, or if you believe that someone is attempting to defraud either you or the UT SELECT Medical plan, please contact BCBSTX for assistance:
- BCBSTX Fraud Hotline: (800) 543-0867
- Link to Fraud Report to complete online: http://www.bcbstx.com/sid/reporting/
For more information about your UT SELECT medical plan benefits, please visit the UT SELECT website at http://www.bcbstx.com/ut/ or contact BCBSTX Customer Service at (866) 882-02034.
1“Consumer Info and Action: What is Health Care Fraud?”, National Health Care Anti-Fraud Association, www.nhcaa.org.
2“Health Care Fraud Overview”, Blue Cross Blue Shield of Texas, www.bcbs.com/blueresources/anti-fraud/
3“Health Care Fraud Runs Wide and Deep”, CNBC, www.cnbc.com
4“What You Can Do to Help Prevent Health Care Fraud and Abuse”, Blue Cross Blue Shield of Texas, www.bcbs.com/blueresources/anti-fraud
Confirm your Annual Enrollment Elections are Accurate
Employees should check their October 1 paystub or earnings statement carefully to ensure that the Annual Enrollment elections are accurate. If the coverages listed on your earnings statement do not reflect the elections you made during annual enrollment, contact your Benefits Office immediately.
Per OEB Administrative Policy 310.6, the only allowable change to Program Coverage during a plan year, other than a qualified change in status, is to correct an administrative error made during the initial period of eligibility or during the annual enrollment period that resulted in an unintended election.
Time Limit to Report Clerical Error
Requests for a change in coverage based upon administrative error must be submitted with “clear and convincing evidence” of the mistake, and must be presented to your institution’s Benefits Office no later than October 31, 2011.
Request Beyond 31 days
If an Employee discovers an error in their election and fails to report the error to the institution Benefits Office within 31 days of receiving their first paycheck of the new plan year, the Employee’s request to correct the error will not be approved.