Health Care Fraud More Likely During the Holidays

Regence Advises Consumers to Take Charge and Protect Themselves

Dec 20, 2005, 00:00 ET from Regence BlueCross BlueShield of Oregon

    PORTLAND, Ore., Dec. 20 /PRNewswire/ -- Regence BlueCross BlueShield of
 Oregon, the state's largest health care insurer, is encouraging consumers,
 especially seniors, to be aware of fraudulent activities and to take steps to
 protect themselves from becoming victims of fraud this holiday season. The
 company offers several suggestions for how consumers can avoid falling for
 scams and frauds.
     "We often see an increase in criminal and fraudulent activity of all kinds
 during the holiday season," said Alex Johnson, senior manager of the Special
 Investigative Unit at Regence. "People usually feel more generous during the
 holidays, and they're in the spending mode. Criminals take advantage of this."
     In 2004, the Centers for Medicare & Medicaid Services stated that
 approximately $85 billion -- five percent of the $1.7 trillion in United
 States health care expenditures in 2003 -- was lost to fraud. According to the
 National Health Care Anti-Fraud Association, an estimated $100 million is lost
 every day on health care fraud.
     Johnson, a former FBI special agent focusing on white collar crime
 investigations as well as a member of the board of governors for the National
 Healthcare Anti-Fraud Association (NHCAA), oversees the fraud investigations
 unit for Regence. Regence fraud investigators uncovered nearly $7.5 million in
 fraud dollars in 2004.
     "We are all hurt by insurance scams," said Johnson. "As health care
 consumers, we all end up paying the price for fraud. Health insurance fraud
 perpetrators are basically stealing from consumers who are paying into the
 insurance system. Whether it's a doctor charging for a procedure that wasn't
 actually administered or a phony insurance agent selling fraudulent insurance
 to a senior citizen, the cost of fraud ends up being passed on to consumers."
     Johnson is quick to point out that the majority of health professionals
 are honest and ethical. "Unfortunately, however, the small percentage that
 makes up the dishonest minority is costing the system billions of dollars
 every year," he said.
     Seniors May be Especially Vulnerable
     Senior citizens may be especially vulnerable to health insurance scams
 this holiday season because of enrollment in the new Medicare Part D
 prescription benefit.
     "Seniors are being solicited by numerous companies to enroll in the new
 Medicare D program," said Johnson. "As they're looking into all of their
 options, seniors need to be very conscientious in protecting their health care
 information, and be careful to enroll only in legitimate programs."
     Johnson says that protecting your health insurance information is just as
 important as protecting your credit card information. He also points out that
 it's very important to take the time to ask questions and to not feel
 pressured to make a quick decision. "Medicare D open enrollment doesn't end
 until May 15, 2006, so there's still plenty of time to look into things," he
 said. "Ask what company an agent is associated with. Take the time to check
 out that company or agent to make sure they're registered."
     According to the FBI's Web site, seniors are particularly targeted for
 fraud for several reasons.
     1)  They are more likely to have money, assets and/or good credit, all of
         which are tempting resources for a con-artist to tap into.
     2)  They were raised to generally be trusting and polite, so they are less
         likely to just say "no" or simply hang up the phone.
     3)  They are less likely to report a fraud, possibly fearing that if they
         admit that they were "taken" by a scam that their family will think
         they are no longer able to make their own financial decisions.
     4)  Their testimonies are easy to discount because memory loss is common
         among this group.
     5)  They are among the group of people most concerned about cognitive
         function, virility, physical condition, anti-cancer products, etc.,
         and are more likely to be enticed by scams offering these kinds of
     Take Charge - Protect Yourself
     Consumers can reduce their chances of being a victim of health insurance
 fraud. "The best defense is a good offense," said Johnson. "Consumers can take
 charge of their own situations by paying attention to the details sometimes
 overlooked by unsuspecting individuals."  Here are some of his tips below:
     -- Protect your health insurance information. Never give your health
 insurance number to telephone or door-to-door solicitors.
     -- Read the "fine print." Carefully review the details of any policy or
 coverage offered before you sign anything, especially sales promotions you
 receive in the mail. Also, make sure the policy you've signed up for is for
 the type of insurance that you need.  One 93-year-old woman who thought she
 was buying valuable medical insurance ended up finding out too late that she
 had purchased maternity insurance instead.
     -- Check out insurers and agents. Unscrupulous companies will sometimes
 use a name that suggests it is associated with a well-known company or
 government agency such as Medicare or Medicaid. Make sure the insurance
 company or agent you've signed up with is legitimate. If a company tells you
 it doesn't have to be licensed or registered with the state, don't do business
 with that company. You can check out an insurance company or agent by
 contacting the Oregon Insurance Division in Salem at (503) 947-7980.
     -- Watch out for "too good to be true" low rates and terms. Beware of any
 policy that costs "pennies a day." The low rate could be effective for only a
 short time - usually 30 days - after which the cost increases dramatically.
 Also, beware of a health insurance company that will accept almost anyone,
 even someone with a pre-existing or serious illness. That could indicate
 you're dealing with a fraudulent company.  Be suspicious if an insurance
 company requires you to pay your premiums in cash, pay for a year's premium in
 advance, or asks that you sign a blank insurance form.
     -- Ask questions. Beware of a company that pressures you to sign up
 immediately because it's your "last chance." Take your time to make a
 decision. Do your homework, and get your information in writing.  Don't be shy
 about talking with friends and family or an attorney or even other insurance
 agencies about the proposed offer or to see if they have heard of the company
 you're considering.
     -- Beware of "free" treatments or products. Lots of community-based
 organizations offer legitimate free screenings of blood pressure, cholesterol,
 vision or other basic health indicators.  However, sometimes "free" medical
 treatments are actually just a way for scammers to acquire your name and
 health insurance information to use in fraudulent billing schemes. Generally,
 you shouldn't need to give out your health insurance information for a
 legitimate free screening or treatment.
     -- Read your statements carefully. Review your Explanation of Benefits
 (EOBs) and billing statements and look for any charges that seem wrong to you
 or any charges for services you don't recall receiving. If you believe you
 have been billed for a procedure that you did not receive, contact your
 insurance company ASAP to report the suspicious charges.
     Oregon Insurance Division
     Oregon Department of Justice
     503-229-5576 from Portland (toll free)
     1-877-877-9392 elsewhere in Oregon
     (toll free)
     email at:
     About Regence
     Regence BlueCross BlueShield of Oregon provides medical, dental and
 related coverage for about one million members in Oregon and in Clark County,
 Washington.  It's part of the Regence Group, the largest affiliation of health
 plans in the northwest and intermountain states, collectively covering nearly
 three million people.  The Regence Group and its affiliates are not-for-profit
 independent licensees of the Blue Cross and Blue Shield Association.  Nearly
 one in three Americans has health care coverage through Blue Plans.  For more
 information, visit

SOURCE Regence BlueCross BlueShield of Oregon