Horizon Blue Cross Blue Shield of New Jersey’s Investigators Ferret out Fraud

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Anti-fraud efforts yield $43.2 million in avoided and recovered losses in 2015

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Through enhanced analytics tools and smart detective work that isolates suspicious patterns and anomalies in claims, the SIU brings an intense focus to fraud prevention.

Health care fraud is usually hidden and committed by a small number of offenders, yet can cost Horizon Blue Cross Blue Shield of New Jersey members and employers millions of dollars in losses each year. That’s why Horizon BCBSNJ continues to invest in state-of-the art detection technology and dedicates an elite team of investigators to catch fraudulent activity and protect the integrity of New Jersey’s health care delivery system. In 2015, this professional team – Horizon BCBSNJ’s Special Investigations Unit (SIU) -- generated $43.2 million in savings -- identified as a combination of monies recovered and losses avoided – and opened 988 new fraud cases.

“It takes the right intelligence tools, a no-tolerance approach and highly skilled investigators to accomplish the SIU’s primary objective, which is to detect and stop fraud activity as early as possible,” said Douglas Falduto, vice president of Administration and Chief Security Officer for Horizon BCBSNJ. “Through enhanced analytics tools and smart detective work that isolates suspicious patterns and anomalies in claims, the SIU brings an intense focus to fraud prevention.”

Increasingly important to the SIU is collaborating with peers in other states and jurisdictions, as well as law enforcement agencies, to share information on trending schemes. “Health care fraud remains a major problem for not only Horizon but for health insurers nationwide, so we are especially vigilant to protect our members from fraud activity that may migrate to New Jersey from other states,” Falduto said.

The “Phantom Doctor’s Office” is among the most serious of trends that is impacting health plans in other states, such as Texas, California and Florida, and has recently surfaced in New Jersey. These are physician shell offices in which fraudulent providers submit bogus claims for reimbursement, then dissolve and vanish. “A phantom office can submit claims by using stolen member identification numbers, so it is vitally important for Horizon members to protect their insurance identification number much like they would protect their social security number,” Falduto said.

Another increasingly common form of fraud is when a doctor creates “The Impossible Day,” or a business cycle in which Horizon BCBSNJ is billed by a physician who claims to treat dozens or even hundreds of patients in a single day.

Fraud and abuse can involve both health care providers and health care consumers. Common examples include:
Providers:

  • Billing for a fraudulent diagnosis
  • Billing for services not rendered
  • Billing for services not furnished as billed, also known as “upcoding”
  • Inappropriate physician/ancillary provider relationships resulting in kickbacks

Consumers:

  • Filing a false claim
  • Using a false ID number
  • Misrepresenting a dependent as eligible for policy coverage

Consumers can take several steps to avoid being victimized by fraud, including:

  • Reviewing their EOB (Explanation of Benefits) after a visit to the doctor or health care facility to make sure the services being billed were services actually rendered;
  • Keeping their insurance ID cards in a safe place, and destroying old ID cards;
  • Contacting the Horizon BCBSNJ Anti-Fraud hotline -- 1-800-624- 2048 – if they become aware of suspicious activity by other card holders or providers.

Horizon BCBSNJ uses tips and the other intelligence it gathers to conduct its own investigations and/or refer cases to law enforcement authorities for criminal prosecution. In 2015, Horizon BCBNSNJ referred 187 cases to the New Jersey Insurance Fraud Prosecutor, the New Jersey Attorney General’s Office, the Federal Bureau of Investigation, and other agencies.

Since 2005, Horizon BCBSNJ’s anti-fraud efforts have saved members $290 million.

About Horizon Blue Cross Blue Shield of New Jersey
Horizon Blue Cross Blue Shield of New Jersey, the state’s oldest and largest health insurer is a tax-paying, not-for-profit health service corporation, providing a wide array of medical, dental, and prescription insurance products and services. Horizon BCBSNJ is leading the transformation of health care in New Jersey by working with doctors and hospitals to deliver innovative, patient-centered programs that reward the quality, not quantity, of care patients receive. Learn more at http://www.HorizonBlue.com. Horizon BCBSNJ is an independent licensee of the Blue Cross and Blue Shield Association serving more than 3.8 million members.
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Thomas Vincz
Horizon Blue Cross Blue Shield of New Jersey
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