Waste, fraud and abuse prevention

Highmark Blue Cross Blue Shield has a zero-tolerance policy on waste, fraud and abuse (WFA), and everyone is responsible to make a difference. Our mission is to protect the overall integrity of the health care system, as well as to protect our members, providers, business partners and stakeholders by administering a comprehensive and effective anti-fraud plan to prevent, detect, investigate and resolve allegations of potential WFA.

What do we mean by waste, fraud and abuse?

Waste

An attempt to obtain reimbursement for items or services where there was no intent to deceive or misrepresent, but the outcome of a billing error caused unnecessary costs to the involved companies. Waste includes overutilization of services not caused by criminally negligent actions. Waste also involves the misuse of resources.

Fraud

A false representation of a matter of fact — whether by words or by conduct, by false or misleading allegations, or by concealment of what should have been disclosed — that deceives and is intended to deceive another so that the individual will act upon his or her legal injury.

Abuse

Provider practices that are inconsistent with generally accepted business or medical practices and that result in an unnecessary cost to the Medicaid Managed Care (MMC) or Child Health Plus (CHPlus) program or in reimbursement for goods or services that are not medically necessary or that fail to meet professionally recognized standards for health care; or recipient practices that result in unnecessary cost to the MMC or CHPlus programs.

Other terms defined

Services not rendered
Billing for goods and/or services that were never delivered or provided

Not medically necessary
Performing inappropriate or unnecessary medical procedures in order to increase payment

Unbundling
Using multiple billing codes instead of one billing code for a drug panel test in order to increase payment

Up-coding
Billing for a higher level of service than was actually provided

Misrepresentation
Forging a physician's signature to obtain pharmaceutical goods

Double billing
Charging more than once for the same goods or services

Underutilization
Not providing adequate medical care to increase profits

Enrollment fraud
Enrolling a beneficiary into a health plan without that person's knowledge

Theft of services
Utilizing someone else's insurance card to receive services either through stealing the card or having it provided by the true card holder

Overpayment
Overpayment defined in accordance with s. 409.913, F.S., includes any amount that is not authorized to be paid by the Medicaid program whether paid as a result of inaccurate or improper cost reporting, improper claiming, unacceptable practices, fraud, abuse, or mistake