Fraud, Waste, and Abuse

* Member Alert

Remember, only go to your Primary Care Provider (PCP) for wellness visits.

If you receive a call or a mailing to go to another provider, call your PCP to ask if the service is needed. If your PCP is unaware of the provider offering the service, call Member Services to see if the visit was requested by your plan for an “in-home” health assessment.

Your PCP is your healthcare organizer; he/she will coordinate all of your healthcare needs and will know all the services recommended for you.

Please contact Member Services toll-free at 1-800-446-8331. TTY/TDD users should call 711. Hours of operation are from 8:00 a.m. to 8:00 p.m., Monday through Friday, from February 15 to September 30; and 7 days a week from October 1 to February 14. This information is available for free in another language. If you have special needs, this document may be available in other formats.

Reporting concerns

The U.S. General Accounting Office estimates that $1 out of every $10 spent for Medicare and Medicaid is lost to fraud and abuse. That means that there is less money to help people like you who depend on these programs for health care. BCBSAZ Advantage is actively working to identify, investigate and prosecute health insurance fraud, but we need your help.

What is fraud, waste and abuse?

Criminal Fraud: Knowingly and willfully executing, or attempting to execute a scheme or artifice to defraud any health care benefit program; to obtain, by false or fraudulent pretenses, misrepresentations or promises, any money or property owned by, or under the custody or control of any health care benefit program. 18 United States Code §1347

Waste: Overutilization of services, or other practices that, directly or indirectly, result in unnecessary costs to the Medicare Program. Waste is generally not considered to be caused by criminally negligent actions but rather the misuse of resources.

Abuse: Includes actions that may, directly or indirectly, result in unnecessary costs to the Medicare Program. Abuse involves payment for items or services when there is not legal entitlement to that payment and the provider has not knowingly and or/intentionally misrepresented facts to obtain payment.

Examples of fraud and abuse

  • Fraud:
  • Altering claims to obtain higher payments
  • Soliciting, offering or receiving a kickback, bribe or rebate
  • Using another person's Medicare card to obtain medical care
  • Abuse:
  • Prescriptions for services that are not medically necessary
  • Billing for a multiple dose medication vial but used for a single dose on one patient
  • Physical health or mental health services that are not medically necessary
  • Ordering labs and test that are not medically necessary

How do I report concerns?

BCBSAZ Advantage takes allegations of Medicare fraud and abuse very seriously. If you think you have been a victim of Medicare fraud or abuse, please use the following phone number to report your concern.

Member Services at BCBSAZ Advantage

  • 1-800-446-8331; TTY hearing impaired users call 711
    Hours of operation
  • October 1 – February 14: 7 days a week, 8:00 a.m. – 8:00 p.m.
  • February 15 – September 30: Monday – Friday, 8:00 a.m. – 8:00 p.m.

How to report directly to CMS

Report anonymously using BCBSAZ Advantage ComplyLine

1-855-729-9719

  • Please leave enough information for us to investigate your concern.

Report by email: AZBlueAdvantageSIU@azbluemedicare.com

Confidentiality

Every effort will be made to protect the identity of the reporting party. There will be no retaliation for good faith reporting.

How do I protect myself?

  • Always check your explanation of benefits to make sure you received the services listed.
  • Never give out personal information, which includes a social security number, Medicare identification number, or BCBSAZ Advantage identification number to callers.
  • Shred documents that contain your personal information.
  • Report any concerns to BCBSAZ Advantage.
  • Educate yourself about how to avoid being a victim.

Where can I learn more?



H0302_1410_2018_CMS Approved 04/20/2018