Fighting Insurance Fraud

The nation's 39 Blue Cross and Blue Shield health insurance plans saved or recovered 47 percent more money last year as a result of three key anti-fraud strategies, a leader of the effort says.

G. Calvin Sneed, senior anti-fraud consultant for the Blue Cross and Blue Shield Association, says the $510 million saved or recovered as a result of anti-fraud efforts in 2009 was partly the result of:

  • A long-term strategy to fortify staff training;
  • An increase in the visibility of special investigations units at each member plan;
  • An increased focus on fraud prevention.

"We've found that the pay-and-chase model for detecting and fighting fraud and abuse in healthcare is very expensive," Sneed said in an interview with "We've found we can become far more efficient if we prevent the bad money from going out the door in the first place."

Sneed acknowledged that another big reason why anti-fraud efforts yielded greater rewards last year was that several large, longstanding fraud cases were resolved.

Types of Fraud
The most common types of insurance fraud continue to involve billing for services that were never rendered or were misrepresented, as well as billing for medically unnecessary services, he said. "But what we have noticed over the last five or 10 years has been an increase in the amount of larger-scale schemes by organized groups."

These criminal schemes, which involve those outside of the healthcare arena attempting to seek payment for bogus services, can prove difficult to detect, he acknowledged.

To prevent and detect all types of fraud, the Blues plans "use off-the-shelf applications as well as customized products," Sneed said. "All of these technologies are beneficial because they provide the ability to detect aberrant patterns in our claims activity. And we've learned how to use this technology better.

"When you can identify hundreds or even thousands of claims, through your analysis, that are a problem, rather than doing claims-by-claims analysis, that's certainly more efficient."

Looking ahead, Sneed envisions a day when improved patient identity verification systems, including biometrics, could play a big role in preventing medical identity theft. But using those technologies "will require a real cultural change in the industry."

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