March 2021
Health Care Fraud is Not a Victimless Crime
Most health care fraud in the U.S. is committed by a small minority of health care providers and/or organized crime syndicates posing as legitimate health care professionals.1 Sadly, the actions of these deceitful few ultimately sully the reputation of some of the most trusted and respected members of our society – our physicians.1
Although the exact amount is unknown, the National Health Care Anti-Fraud Association (NHCAA) estimates conservatively that 3% of all health care spending – or $68 billion – is lost to health care fraud annually.2 Other estimates by government and law enforcement agencies place the loss due to health care fraud as high as 10% of our nation’s annual health care expenditure – or a staggering $226 billion – each year.3 And the cost of health care will only continue to rise, which means the price tag associated with health care fraud will rise too, unless we can work together to combat it.
But financial losses caused by health care fraud are only part of the story. Victims of health care fraud are people who are exploited and subjected to unnecessary or unsafe medical procedures, whose medical records are compromised or whose legitimate insurance information is used to submit falsified claims. Other common nonfinancial negative consequences of health insurance fraud include, but are not limited to:
- Inaccurate patient records resulting from the documenting of false diagnoses, treatments and medical conditions in legitimate medical histories
- Theft of patients' finite health insurance benefits
- Physical risk to patients by subjecting them to unnecessary and/or dangerous medical procedures because of greed
- Medical identify theft
At Blue Cross and Blue Shield of Illinois (BCBSIL), we actively participate in inquiries and investigations to accurately identify and appropriately address potentially fraudulent activities. Our Special Investigations Department (SID) is committed to fighting fraud, reducing health care costs, and protecting the integrity of the BCBSIL provider network. The SID offers two ways to take action, 24 hours a day, seven days a week:
- File a report online, or
- Call the Fraud Hotline at 800-543-0867. All calls are confidential, and you may remain anonymous.
Always ask to see the member's ID card for current information and a photo ID to help guard against medical identity theft.
1 National Health Care Anti-Fraud Association, The Challenge of Health Care Fraud, https://www.nhcaa.org/resources/health-care-anti-fraud-resources/the-challenge-of-health-care-fraud.aspx
2,3 NHCAA, The Problem of Health Care Fraud, Feb. 9, 2011,
http://web.archive.org/web/20110209140325/http:/www.nhcaa.org:80/eweb/DynamicPage.aspx?webcode=anti_fraud_resource_centr&wpscode=TheProblemOfHCFraud
The above material is for informational purposes only and is not a substitute for the independent medical judgment of a physician or other health care provider. Physicians and other health care providers are encouraged to use their own medical judgment based upon all available information and the condition of the patient in determining the appropriate course of treatment. The fact that a service or treatment is described in this material is not a guarantee that the service or treatment is a covered benefit and members should refer to their certificate of coverage for more details, including benefits, limitations and exclusions. Regardless of benefits, the final decision about any service or treatment is between the member and their health care provider.