Fraud, Waste and Abuse Program

Studies have determined that healthcare fraud is the single largest contributor to the increase in healthcare costs. It's a serious crime and accounts for an estimated 3-10% of all healthcare spending. We take it very serious and are committed to fight against it.

Common Examples of Fraud, Waste and Abuse

Fraud, waste and abuse occurs in a variety of ways. The most common include:

Provider Actions

  • Billing for services or supplies that were not provided or needed
     
  • Filing a claim for a more expensive procedure than was actually performed
     
  • Billing for a covered service when the true service was non-covered
     
  • Omitting or misrepresenting information about a condition, symptom or service performed

Member Actions

  • Using an insurance ID card that belongs to someone else
     
  • Adding someone to a policy who is not eligible for coverage
     
  • Receiving narcotic prescriptions from several physicians, through deceit
     
  • Forging or altering bills or receipts

For more examples and a detailed program description, click here.

How We Fight Against Fraud, Waste & Abuse

At BCBSVT we take a proactive approach to detecting and investigating potential fraud, waste and abuse.

  • We have a special investigative unit dedicated to preventing, detecting and investigating FWA, staffed with trained professionals who have many years of health care and health insurance experience.
     
  • We use sophisticated software to continually analyze our healthcare claim patterns and investigate red-flag situations were provider billing exceeds normal ranges.
     
  • We partner with industry-leading firms who specialize in identifying “outlier” claims and auditing provider’s records to ensure billings are correct.
     
  • We maintain an active fraud hotline where our members and providers may report suspected fraud.
     
  • We recover millions of dollars in erroneous and unsupported claims every year.


What you can do

Help us control rising healthcare costs. If you suspect fraud, waste, or abuse in the healthcare system, you should report it to BCBSVT and we will investigate. Your actions may help to improve the healthcare system and reduce costs for our members, customers, and business partners.
 

Tips when reviewing your Explanation of Benefits (EOB)

Help us identify potential FWA situations by reviewing your explanation of benefits or claims (available within our secure Member Resource Center) to ensure that reported services where actually received.  During your review please keep these sometimes confusing scenarios in mind:

  • Some healthcare service providers bill for two components: facility and professional.

For example, if you receive laboratory, x-ray and imaging services you will likely see two separate lines on your EOB:

  1. Hospital where the x-ray or laboratory services were performed (facility component)

  2. Doctor who read the x-ray or laboratory service (professional component)

It’s normal and expected to see two separate provider names on your EOB in these scenarios. It’s not considered fraud, waste or abuse.

  • Injections/Immunizations, intravenous (IV) and blood draws fall under the type of service (TOS) category ‘Surgery.’

Although these types of services aren’t what typically come to mind when you think surgery, this is how they would appear on your EOB.

 

Report suspected fraud, waste, or abuse one of these ways:

PhoneE-mailWrite Us

BCBSVT Fraud Hotline:
(833) 225-3810 for BCBSVT Members (non-FEP)
(800) 337-8440 for FEP Members

Fraud_issues@bcbsvt.comBlue Cross and Blue Shield of Vermont
PO Box 186
Montpelier, VT  05601-0186
Attn:  Fraud, Waste, Abuse & Recovery Department

 

You may remain anonymous if you prefer. All information received or discovered by the BCBSVT FWA Special Investigations Unit (SIU) will be treated as confidential, and the results of investigations will be discussed only with persons having a legitimate reason to receive the information.