September 8, 2003
Health care fraud by a few raises costs for us all
- by Ralph H. Weber, M.D., Vice president, medical affairs, Blue Cross and Blue Shield of Kansas
There is a plague on our health care system today. It does not resemble the boils or parasites of ancient Egypt, but be assured that this plague wreaks havoc for people just the same. When unscrupulous people inappropriately use the health care system for personal gain, the fraud they commit raises the cost of health care for all of us.
Health care fraud is expensive. The National Health Care Anti-Fraud Association predicts that fraud costs Americans between $33 billion and $55 billion each year, or roughly 3 percent to 5 percent of our nation’s health care expenses. As fraud and abuse inflates the true cost of health expenditures, it raises the cost of health insurance for everyone.
Equally concerning to me is that many people don’t see the link between fraud and higher costs. The Wall Street Journal has reported that nearly one in four Americans say it is acceptable to defraud an insurance company, based on a survey by Accenture Ltd.
Fraud comes in many forms, and is committed by both people who provide health care services and by those who receive services. Some common types of fraud you should be on the lookout for include:
- Billing for services not received.
- “Upcoding” or charging for a more expensive service than the one provided.
- Including an ineligible family member on insurance coverage.
- Providing unnecessary services.
- Misrepresenting services provided by performing one not covered by insurance and then billing it as a covered service.
- “Unbundling” or charging separately for procedures that should be billed as a single treatment.
- Seeing several doctors at one time for the purpose of obtaining multiple prescriptions for the same drug.
- Delivering health care services that the person is not licensed to provide.
The Accenture Ltd. survey also reports that 39 percent of respondents said they were not likely to report someone who had committed insurance fraud. Again, that clearly illustrates the fact that many of us don’t understand we all pay for the activities of those who abuse the system. I encourage you to help fight health care fraud by:
- Thinking of your health insurance card as your credit card. If lost or stolen, an insurance card could be used to gain access to drugs and services that may permanently appear on your medical history.
- Examining the claims reports you receive from your insurer to make sure the services billed were the services you received when you visited a health care provider. If there is a question or discrepancy, call the provider’s office to make sure it wasn’t a clerical error.
- Reporting suspected health care fraud to your insurance company. Health insurers are dedicated to investigating alleged fraud in order to protect their members and the system.
Ralph H. Weber, MD, is vice president of medical affairs for Blue Cross and Blue Shield of Kansas. He spent 10 years in private practice in Salina before joining the health insurer in 1988. He was promoted to vice president in 1990.
Blue Cross and Blue Shield of Kansas is an independent licensee of the Blue Cross and Blue Shield Association. BCBSKS is the state's largest health insurer, serving all Kansas counties except Johnson and Wyandotte.