How to Report Health Care Fraud
Health care fraud, waste and abuse create a negative effect on the health care industry. These cost billions of dollars each year. It impacts all of us in the long run. Health care fraud leads to:
- Higher health care costs
- Limited health care resources
- Lower confidence in our health care system
Avoid Health Care Fraud
Beware of “free” services.
Beware if you are asked to provide your health insurance information for a “free” service. The service is probably not free. Your policy may be billed.
Never share your personal information with callers you have not confirmed.
Check your explanations of benefits (EOBs) or claims on a regular basis.
If your plan provides EOBs or claims, be sure to check them. Contact BCBSNM if you have questions. Use the Member Services number on the back of your member ID card.
Reasons to Contact BCBSNM
BCBSNM can check your claims. We may refer concerns to our Special Investigations Department (SID). Here are some reasons why SID may review a claim:
- You did not request or receive a service or supplies.
- There is a concern with repeat billing of a service or supplies.
- You shared your health insurance ID number during a marketing call and now you have concerns.
We all need to work together to reduce health care fraud. BCBSNM works to fight fraud with help from our:
- Members
- Providers
- Employer groups
- Producers
- Local, state and federal agencies and law enforcement
BCBSNM's SID staff includes people from diverse backgrounds such as:
- Medical providers (doctors and nurses)
- Professional coders
- Insurance industry experts
- Law enforcement
SID also has a Data Intelligence Unit to partner with SID investigators. They work to find and stop fraud, waste and abuse. When needed, SID refers fraud cases for criminal prosecution.
Tips to Prevent Health Care Fraud
Reducing health care fraud is a joint effort between Blue Cross and Blue Shield of New Mexico, its providers and its members.
Here are some ways you can help prevent fraud:
Understand what your plan covers. Know what you are responsible to pay. Find out if your plan requires you to pay a deductible or copay.
Guard your health plan member ID card, Social Security Number and other personal information. Report stolen or lost personal information at . Also, alert Member Services if your identity has been stolen. You can request a new member ID card if needed.
Be aware of phony sales pitches over the phone. Do not share your insurance or personal information.
Watch out for phishing scams that can trick you into providing your personal information. Check to learn more.
Never lend your member ID card to someone else.
Don't give out your information if medical services or equipment are offered as "free." Be sure you understand what is "free." If something is "free," there should be no reason for you to share your health plan information.
Before you have a medical test or treatment, ask your health care provider exactly what they want you to have and why.
Monitor what prescription drugs you use. Make sure the medicines billed to BCBSNM are correct.
How Do I Report Potential Concerns?
If you suspect fraud, there are ways to report it.
Report by Phone
To report fraud, you can call:
Medicaid Member Services at 1-866-689-1523
BCBSNM Fraud Hotline at 1-800-543-0867
Calls are always confidential. You can remain anonymous or let us know if you want to be contacted.
Report by U.S. Mail
Blue Cross and Blue Shield of New Mexico
Special Investigations Department
5701 Balloon Fiesta Pkwy. NE
Albuquerque, NM 87113
