Have you ever questioned the care you received from your doctor? Sometimes your gut instinct is telling you that something’s off. You might be witnessing fraud, waste or abuse. Fortunately, you can take action to protect yourself and your family.  

Meet Sandra. She’s at her doctor’s office because she has a sore throat that she just can’t seem to kick it. Sandra explains her symptoms, and her doctor orders a strep test, and an x-ray, and an EKG. 

Now wait a second… Sandra isn’t coughing or having trouble breathing, so why does she need a chest x-ray? And why the EKG? She didn’t mention any chest pain. These types of situations are actually really common. And it can pay off to pay attention – and I do mean that literally. 

 Sandra might be witnessing fraud, waste or abuse.  

“Fraud” is an intentional act of deception for unlawful gain. 

​“Waste” happens when someone uses too many health care services or doesn’t use resources correctly. ​ 

“Abuse” is slightly different because it involves excessive or inappropriate actions that aren’t consistent with acceptable business or medical practices. Abuse causes someone to lose money – either directly or indirectly. This could be the provider, the insurer or even you — the patient.​  

If you get your insurance through your employer, then they may be also be losing funds from fraud, waste and abuse.  Even worse, you or a loved one may experience complications from a test or procedure that won’t likely help solve your health problem.   

Fortunately though, you can take action to protect yourself, your family, and your employer’s ability to offer you quality healthcare benefits.  

Before we go any further, let’s be clear. There are a lot of great doctors out there – caring individuals who are on a mission to save lives. They might make a few mistakes along the way, but making a mistake isn’t the same as committing a crime on purpose. The person’s intent is what matters most. 

However, inefficient practices can still be a problem. Careless action can drive up costs, reduce quality, and that’s when the alarm bells begin to go off.  

Doctors may feel the pressure to bring in more income and see an opportunity to bend the rules. Before you know it, they’re being intentionally deceptive, and they’re rationalizing their shocking—and illegal—behavior. 

These actions have a huge economic impact on our health care system. Every year, we spend about 3 and a half trillion dollars on health care in this country.  

$750 billion of that is lost to fraud, waste and abuse. And the vast majority of THAT is due to waste. 

Even doctors themselves see a need for change. More than 70% admit that physicians perform tests and procedures that aren’t necessary. 

In a study of 1.3 million patients in Washington state, more than half underwent unnecessary treatment. The study revealed a lot of expenses – costs that are likely passed on to consumers through premiums, copays or deductibles.  

But it’s not just about the money. At the end of the day, your health is your wealth. What if a doctor recommended an unnecessary back surgery that led to complications? That could impact your ability to walk forever.  Or you could suffer from a known complication from a surgery like infection.  That could be painful, and a hardship on you and your family.  So, pay attention to what the doctor is ordering for you and ask questions if something doesn’t make sense. 

Unfortunately, sometimes doctors are intentionally deceptive: 

• Providers might misrepresent their services by billing insurers for procedures under incorrect codes. Think of it as an effort to get paid for something that’s not covered. 
• Doctors and hospitals have also been known to practice “unbundling.” That’s when procedures and supplies are billed separately, instead of packaged together for affordability. 
• Then there’s “up-coding.” That’s when a provider bills for a more expensive procedure than was actually performed. 
• Some also fraudulently perform and bill for services that a patient didn’t actually need. 
• And sometimes a provider gets really bold. They bill for a service that wasn’t even performed.  

All of these actions are against the law, so they’re considered fraud – pure and simple. 

As you can see, it has an impact on real people, like you and me. It may force insurers to increase our premiums and copays, and it might subject us to unnecessary or unsafe medical procedures. 

Health insurers want their members to be well.  But every medical procedure has risk and possible complications.  That’s why they established the use of prior authorizations, so you can get the care you need – without the unnecessary procedures and the unnecessary risk. But there are also some practical steps you can take to prevent fraud.  

Review your Explanation of Benefits statements. Does everything make sense? Is everything accurate? 

You can also protect your health information. Only share personal details with your health care provider. Never lend your insurance card to someone else.  Trust me on this.  

It’s also important that you take charge of your own health care. Try to understand your treatment programs. Ask your physician for more information if you’re skeptical about a test or referral.  

And lastly, be cautious of free health care services. If it’s really free, you don’t need to provide your insurance information! And if it seems ‘too good to be true’, it probably is. 

When something seems off, give your insurer a call.  Blue Cross and Blue Shield of Texas members can call the number right here on the screen.  That gut-feeling you might have, might actually be right, and we have dedicated teams ready to investigate.   

By reducing fraud, waste and abuse, Texans like yourself have a better chance of becoming healthier – physically and financially.   

And that’s everyone’s end goal.