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Policies and Best Practices

Fraud, waste, and abuse

Find out how to report and fight health care fraud, waste, and abuse (FWA).
Report FWA

How do we fight FWA?

At Blue Cross and Blue Shield of North Carolina (Blue Cross NC), our mission is to improve the health and well-being of our customers and communities. One of the ways we do that is by working hard to protect our members, providers, agents, and business partners from health care fraud, waste, and abuse. This helps lower health care costs, protects personal information, and prevents future threats. 

To maximize our ability to prevent FWA, Blue Cross NC relies on its Special Investigations Unit (SIU). Our SIU works collaboratively with internal partners and external bodies, such as law enforcement and delegated entities, to identify, report, and prevent FWA. 

Learn More About SIU

What is health care FWA?

Fraud

An intentional or criminal misrepresentation resulting in personal or financial gain.

Waste

Practices that, directly or indirectly, result in unnecessary costs, such as overusing services. Waste is generally not considered to be caused by criminally negligent actions but rather by the misuse of resources.

Abuse

A reckless disregard or conduct that goes against and is inconsistent with acceptable business and / or medical practices resulting in greater reimbursement or services.

Examples of possible health care FWA

  • Identity theft 
  • Billing for services not rendered 
  • Billing for a higher level of service than was provided 
  • Provision / billing for services not medically necessary 
  • Falsification of medical documentation / medical condition to gain prior authorization 
  • Misrepresentation of place of service 
  • Misuse of medical modifiers 
  • Misrepresentation of the date a service was provided 
  • Unbundling of services otherwise included in the primary procedure 
  • Falsification of health plan enrollment information 
  • Waiving of copay or coinsurance responsibility 
  • Misrepresentation of medical condition / treatments to obtain prescriptions 
  • Obtaining prescriptions and using / sharing those drugs for a purpose not intended 
  • Collusion and / or kickback in conjunction with the provision of health care services 
  • Falsification of diagnosis information to inflate Hierarchal Condition Coding (HCC) 
  • Misrepresentation of plan network or benefits to induce beneficiary enrollment 
  • Overprescribing of prescription drugs, including opiates 

How to report FWA

You have 4 options for reporting suspected fraud, waste, and abuse: online form, phone, email, or postal mail. When reporting, please provide as much information as possible to help our investigation team conduct a thorough review of the concern. One of our team members may reach out to you to gather additional information.

Online report form

Submit our online Fraud and Abuse Report Form. You can remain anonymous.

Complete Report Form

Confidential hotline

Call to report FWA with our 24-hour confidential hotline.

800-324-4963 (toll-free) 919-765-2464

Email

Email our SIU team at SIU@bcbsnc.com to report suspected FWA.

Note: Emails may not be secure. We cannot guarantee the privacy of information sent by email. Please use caution when providing personal information. It is best to only provide enough information for the SIU to contact you.

Email SIU

Mail

Report suspected FWA by mailing our SIU team:

Blue Cross NC SIU

PO Box 25431

Durham, NC 27702-5431

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About our Special Investigations Unit (SIU)

The Blue Cross NC SIU is a dedicated team that often receives additional targeted support from our Legal Department, Healthcare Services Department, and the Data and Analytics team. This team also has additional support throughout the organization.  

The SIU approach is anchored around a data-driven philosophy focused on early detection of aberrant behavior and a retroactive review of unusual trends and patterns. This unit leverages a multi-tiered approach to detect, prevent, investigate, and correct potential FWA across the enterprise. The SIU proactively searches for organizational risks and potentially fraudulent activity. Once FWA is identified, the course of action may include outreach and communications with impacted parties, cooperation with state and federal law enforcement officials, and engagement in the Department of Insurance referral process.