How BCBSRI is fighting healthcare fraud, waste, and abuse 

$60 billion is lost to healthcare fraud, waste, and abuse (FWA) in the United States each year, according to the National Healthcare Anti-Fraud Association (NHCAA). And that’s a conservative estimate. What is troubling, however, is that everyone pays the price—in the form of higher insurance premiums, increased healthcare service costs, and human suffering (one example being the opioid crisis, as there are many FWA cases related to substance abuse issues).

Here at BCBSRI, a small but significant group is working tirelessly to address these problems. Led by retired Rhode Island State Police Superintendent Brendan Doherty, the Special Investigations Unit (SIU) works to identify and investigate potential fraud cases involving members or providers. Coupled with years of professional experience and continual education, the team uses sophisticated technology and hands-on investigative techniques to resolve FWA cases. SIU takes a team-oriented approach, enlisting the support of the BCBSRI pharmacy benefits manager, case management team, medical director, and local, state, and federal law enforcement as needed.

Adding to their challenge is the fact that many Rhode Island and Massachusetts healthcare entities are effectively isolated from one another, a situation that makes it even easier for certain types of fraud or abuse to occur. Imagine, for instance, how an individual might visit multiple providers and pharmacies across both states to obtain and fill prescriptions for controlled substances. Of course, not all FWA cases involve BCBSRI members. Provider fraud is another concern. Among the most common types are billing for services not provided, overcharging for services, or over-prescribing medications. 

The good news? Whatever the potential problem, SIU is on it. And that benefits all of us.