Fraud and Abuse

Help us protect your health care dollars.

Improper billing and submission of erroneous claims drive up the cost of health care. If you suspect that the claim information on your Blue Cross of Idaho Explanation of Benefits (EOB) or your health care provider's direct billing is improper or erroneous, you may call the Blue Cross's confidential hotline at 1-800-682-9095 or email us.

Definitions

Fraud -- Health insurance fraud is a willful act to deceive an insurance company for unlawful gain.

Abuse -- Health insurance abuse is an action against an insurance company that is inconsistent with acceptable business and/or medical practices that results in an unfair gain to the claimant.

Difference Between Fraud and Abuse

The major difference between fraud and abuse is in the area of intent. In fraud, the intent is to deceive or misrepresent. With abuse, the intent is not criminal, but the acts are inconsistent with accepted sound medical, business, or fiscal practices which directly, or indirectly, create unnecessary costs.

Types of Fraud

The types of fraud are limited only by the imagination of the person attempting to illegally obtain money. However, the types can be grouped into three major categories, those involving services, those involving charges, and those involving identity.

Services -- Fraudulent activity involving services generally appears as: 1) services that were not provided; 2) services that were not necessary; 3) services that were misrepresented; and 4) incidents where the date of service was misrepresented.

Charges -- The two most common types of fraud involving charges are where the charges are misrepresented and where the provider waives the copayment.

Identity -- The two types of identity fraud occur when a member attempts to enroll an ineligible person on their application, and where a non-member uses a member's identity to obtain services to which they are not entitled.