Horizon Blue Cross Blue Shield of New Jersey said Tuesday that its anti-fraud efforts saved $45.4 million in 2014, which includes both money that was recovered and losses that were avoided through early detection of fraud schemes. The company said this is the highest recovery/prevention total since Horizon created its Special Investigations Unit…Horizon said that, since 2005, its anti-fraud efforts have saved $261 million.
“Our SIU has progressively enhanced Horizon’s analytics capabilities, which has allowed us to be more intuitive in our anti-fraud efforts, and better capable of detecting and stopping fraud in its early stages,” said Douglas Falduto, vice president, administration, and chief security officer for Horizon. “Through state-of-the art software and smart detective work, we’re constantly improving our ability to recognize and investigate questionable claims and claim trends closer to real time.”
Horizon said that, in 2014, the SIU opened 1,318 new cases of suspected fraudulent activity and said many investigations begin with tips reported confidentially to its anti-fraud hotline: (800) 624-2048. Horizon said the hotline received 2,450 calls in 2014.
The company said fraud and abuse can involve both health care providers and health care consumers. Common examples include:
- 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.
- Filing a false claim;
- Using a false ID number;
- Misrepresenting a dependent as eligible for policy coverage.
“Horizon is committed to ensuring that members’ health care dollars are used appropriately. We encourage our employees, health care providers and members to be on the lookout for suspicious activity or billing and report it to the SIU,” Falduto said.
According to National Health Care Anti-Fraud Association estimates, tens of billions of dollars are lost to health care fraud each year.
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